$825 million announced in pharmacy program changes

Remunerated MedsChecks are set to double and payments for DAAs streamlined under an $825 million provision for pharmacy over the next three years

The provision of $825 million is aimed at supporting and improving Australians’ access to medicines under the “Improving Access to Medicines – support for community pharmacies” measure.

It comprises the $600 million in the 6CPA for pharmacy programs, plus the $225 million to go to community pharmacists and pharmaceutical wholesalers as a result of lower than forecast script volumes.

Changes are set to begin from 1 July 2017.

Last week Guild national president George Tambassis said the Guild was engaged in “very detailed and urgent discussions with the Department of Health to finalise these allocations by 1 July”.

Dose Administration Aids

The current Pharmacy Practice Incentive payment for DAAs will wind up on 30 June 2017, though claims for DAAs provided in June may be submitted between 1 July and 14 July 2017.

From 1 July, community pharmacies participating in the DAA program will receive $6 per patient per week as a contribution to the cost of providing the service to eligible patients.

Pharmacies may apply an additional consumer charge for the DAA service at their own discretion.

To support the collection of information and monitor the program’s delivery of health outcomes for patients, they will be required to collect data for five patients that receive services.

MedsChecks and Diabetes MedsChecks

From 1 July 2017, the number of MedsCheck and Diabetes MedsChecks that can be conducted and claimed by community pharmacies are set to double, from 10 per calendar month to a total of 20 per calendar month.

Again, to support the collection of information and monitor the program’s delivery of health outcomes for patients, community pharmacies will be required to collect data for the patients funded under this service. 

Staged Supply

The current Pharmacy Practice Incentive payment of $1,300 a year for Staged Supply will come to an end on 30 June 2017.  

From 1 July 2017, community pharmacies participating in the Staged Supply program will receive a new weekly fee-for-service per patient for up to four eligible patients per pharmacy.

Community pharmacies will be required to collect data for the patients funded under the service. 

HMR program

The HMR program will continue unchanged from 1 July 2017, but a review of the current MBS item 900 eligibility criteria is to be undertaken.

Potential changes to patient eligibility criteria, the inclusion of two new in-pharmacy follow-up services, and criteria to increase access to the service for Aboriginal and Torres Strait Islander patients are anticipated to commence in early 2018.

More information is available here.

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NOTICE: It can sometimes take awhile for comment submissions to go through, please be patient.


  1. Andrew

    Can we please have someone TRUTHFULLY explain WTF is going on with MedsChecks and HMRs?

    Funding and numbers INCREASED for the non-evidence based Medschecks……while the strongly evidence based HMRs remain capped despite clear evidence of increasing hospitalisations due to medication misadventure, poor QuM, and sub optimal patient outcomes.

    Not only that there’s suggestion that HMRs might end up being bastardised into Medschecks Lite with a compulsory 2-visit follow up with a community pharmacy whenever this three-year review of the item 900 is complete.

    The 2014 press release that accompanied the HMR cap mentioned that the Guild has taken over administration of the 6CPA funding – it seems clear that as a result they’ve completely eschewed any notion of improving public health outcomes for the commercial considerations of their members.

    Do I understand this correctly? Can someone please explain or clarify this for me because I feel like I’m the only one caring just how dodgy this all is.

    • John Wilks

      Andrew you understand the professionally biased processes and the nest feathering very well indeed.

      HMRs are are proven world class primary prevention strategy that my colleagues overseas look upon with envy and awe.

      And yet, because the Guild has all the say at the negotiating table it would appear to be serving only the needs of a minority of the profession … pharmacy owners.

      A few questions swirl around my depressed mind:
      1. How many of the negotiating team are accredited pharmacists regularly doing 10 or reviews each month?
      2. Why does an organisation that i do not belong to decide my professional future?
      3. Why do i have to make clinical prioritizing decisions about who i see this month because i am close to my 20 HMRs per month?
      4. I have been now accredited for 20 years and have a strong relationship with > 20 drs hence my continual carry over each month of HMRs.
      5 . The current situation is an unjustified restriction of trade which places patient safety at risk.

      Am i angry?
      John Wilks

      • Karalyn Huxhagen

        well said John. I am not against Medscheck in its correct place but we know they are abused by those not so scrupulous. why the temporary cap on HMRs has not been removed and the ‘extra’ money that could have been given to this well researched primary health service has been used to extend the payment program of a non proven service begs disbelief. where was the ministers delegate in this negotiation. Under Susan Lee we were promised that all of the programs would be meticulously investigated for improvement in patient outcomes before being given an extension or improvement in funding. HMR has delivered but still missed the increases. Beggars belief. The follow up being done in community pharmacy was ridiculous when floated by PGA at tranche 1 meetings and has gained ground when Govt had said show us the economics of this addition to the program. How did that happen? No one is in my corner at these negotiations least of all PGA

        • Willy the chemist

          Ideally HMRs should be remunerated through Medicare. Hence the move to get it funded outside of the CPA and within the framework of MBS. This will be a win for accredited pharmacists and all pharmacists.
          It is fundamentally outside the scope of Community Pharmacy, performed by Accredited pharmacists in the patients’ residence.
          For it to be successful, firstly it has to be funded correctly.
          Proprietor pharmacists are sometimes HMR accredited pharmacists. Let’s try not to disparage each other everyone.
          Yes HMRs is evidence based. Yes Medscheck is less evidenced based but it is not without evidence. If that be the case, many activities is without “evidence”.
          Yes, if truth be told, HMRs were also ‘abused’ by those not so scrupulous with their software farming.

          Susan Lee was very unsupportive of pharmacy. Remember the $1 CoPayment Discount that she initiated all at the 11th hour.
          And the long inexplicable delays in the Professional Services programs. Hell, under her leadership, the department couldn’t even decide on how to start the trial!
          She had no intentions of honouring the risk share clause within the CPA. All she did was obfuscate and obstruct pharmacy going forward.
          Minister Greg Hunt is the opposite. He has been understanding of the plight of pharmacy and healthcare professionals in general.

          The situation with a cap on HMR is not ideal. It needs to change. As to why an organisation that one does not belong to decide the fate of HMRs, well, that’s simply because it is currently under the envelope of the CPA. This is fundamentally a funding issue, accredited pharmacists/all pharmacists should push for the worthy HMRs to be funded through MBS.

          • Jarrod McMaugh

            Agree with everything here except the “fundamentally” bit. HMR is fundamentally a part of a patient’s ongoing care with regards to QUM, and should involve all aspects of this (which includes the community pharmacy).

            Most of the accredited pharmacists I know are community pharmacists (and very good at both roles) – it’s not like they can extract one role from the other.

          • Willy the chemist

            Yes, fundamentally I was incorrect on this point 🙂

          • Debbie Rigby

            Willy the chemist – can you please direct me to the evidence for MedsChecks.

          • Willy the chemist

            Here we go again!
            Debbie can you please direct me to the evidence that unscheduling of OTC Codeine will not result in more patients being prescribed more potent narcotic and the resultant dependency on these potent analgesics?
            And Debbie, can you please also direct me to the evidence that unscheduling of OTC codeine is superior to MedASSIST real time monitoring in the recording, management, control and monitoring of codeine based medicines?
            You must have good evidence in advocating up-scheduling against the risk of potentially stronger narcotics use and a lack of real-time monitoring?

            MedsChecks is an in-pharmacy review of a patient’s medicines. It focuses on the relationship between the community pharmacists and patients, leveraging their position and skills in counselling, education and improving their understanding of their medicines. This leads to better self-management. The added benefit of the interactions may assist the pharmacists in identifying issues or problems the patients may have, whether it be their medical conditions, their medicines or even the patients’ understanding of their medicines.
            It goes a little to pay the pharmacists for their time, skills and trainings, incentivise them to spend quality time with their at risk patients to manage, educate, improve understanding and quality use of medicines.

            Debbie, this is essentially what thousands of pharmacists do both in Community pharmacy and hospitals, everyday and everywhere. The MedsChecks just give them an incentive and opportunity to do so.
            Do you mean there is NO EVIDENCE in our job? Or do you rather community pharmacists continue NOT to be remunerated properly at the coalface?

          • Andrew

            >>>This leads to better self-management.

            Citation required.

            >>>>The added benefit of the interactions may assist the pharmacists in identifying issues or problems the patients may have, whether it be their medical conditions, their medicines or even the patients’ understanding of their medicines.

            Citation required.

          • Willy the chemist

            Sigh. Would it be fair to comment that it is often the very pharmacists that we have self deprecating altitudes on our self worth and values?
            Patients self manage their medicines everyday. Pharmacist educate, counsel, advice, intervene, etc etc everyday. It is fair to say we assist patients in self managing their medications.
            One does not have to question every little things pharmacists do, esp from another colleague. Its condescending and insulting.

            I know there is a beneficial outcome to a HMRs. Do I need to be querying everything a HMR pharmacists do? Suffice to say that I agree that our business model is not ideal, and I’m empathetic towards our cause.

            I wish we can have HMR listed on MBS. Why can’t some HMR accredited pharmacists come together to gather evidence on HMRs and present to the government for MBS listings?

            Also it would be nice that we try to get HMRs rebates from private health insurances. Come on, I challenge the HMR accredited pharmacists to do this please?

          • Debbie Rigby

            Willy the chemist, there is no doubt in any pharmacist’s mind that we provide significant benefit to patients on medication management.
            But it is reasonable to expect some evidence (economic, clinical humanistic outcomes) for a funder e.g. government to remunerate for services beyond that of dispensing.
            At this point in time HMRs, RMMRs and DAAs have that evidence, MedsChecks do not.

          • Willy the chemist

            Debbie, forgive me if I’m incorrect. Ultimately as pharmacists having our work continually questioned and negatively downplayed is disheartening, especially coming from a fellow pharmacist. There is a sense of overall negativity and division within the profession…often in the guise of “evidence”.
            MedsChecks have less evidence because they are newer…and to be fair, maybe not enough research into cost effectiveness. More data are being collected.
            However if there are more evidence of cost effectiveness of HMRs other than VALMER economic study, please can you quote the studies?

            Even in VALMER study, ” in the baseline scenario, the predicted health resource savings was insufficient to offset costs. ”
            The cost of a HMR is only offset by the cost savings in the UPPER QUARTILE of patients.

            Hence as we speak, the current criteria for HMRs cannot be said to be purely “evidence-based”.
            But Debbie, I know one thing. Numbers can be made to dance. Slice and dice anyway anyhow one likes in order to derive at an answer.

            If you ask me, my humble opinion is that a properly conducted HMR and/or Medscheck offers significant cost savings and qaly.

            As we all know, one can argue any angles you like, the Americans argue for complete privatisation and deregulation of healthcare. And I’d argue that the raison d’être for keeping healthcare from being privatised is to just look at the American model today.
            One could also say the same with the gun laws.

            Lastly, if we have all the evidence of HMR being cost-effective, evidence-based and best practice health care, then Debbie, as a leader accredited pharmacist, you should apply to MSAC for a Medicare listing.

            If community pharmacists are successful, we as pharmacists all celebrate. If accredited pharmacists are successful, we as pharmacists all celebrate. Basically we celebrate each others’ successes and we moan each one’s struggles.

            And finally in the matter of codeine, Primum non nocere.
            Firstly there are evidence that codeine 15mg OTC doseforms do confer some benefits.
            Secondly there are insufficient evidence that up-scheduling reduces adverse events and abuse.
            Thirdly, there are insufficient evidence that up-scheduling will not increase stronger narcotic analgesic prescribing habits and/or requests. (Human behaviour)
            4th, that up-scheduling will not result in increase a&e hospital presentation esp. after hours – due to lack of bulk billing, long appointment waiting time, days to get available appointment etc
            (The irony is that many of these are acute patients)
            5th, IMPORTANTLY, up-scheduling is actually ceasing a working real-time monitoring system MedASSIST. Whilst one can claim anything they wish, we do know from the law enforcement officers that a similar real time monitoring system Project STOP do confer a lot of positives and that the law enforcement officers are usually the first people to call for it to be nationally adopted.
            6th LASTLY, we know that codeine deaths are usually inconclusive as they are often consumed with other pharmacologicals. And that most opiate overdose and deaths happen to be prescribed drugs.

            So no.2,3,4,5,6 without sufficient evidence to support codeine up-scheduling. These are based on one’s preconceived biases and assumption that up-scheduling is superior to proper pharmacist control. This is what I call preconceived idea or confirmatory bias.

          • Big Pharma

            Does a letter from the PGA indicating medscheck program expansion count as evidence?

          • Debbie Rigby

            I meant clinical evidence of benefit to consumers in reducing medication misadventure. I have said many times that MedsChecks are a good program if conducted according to the program rules. They potentially can improve adherence and persistence to meds through helping patients understands the benefits and risks. They can be used to assess and improve inhaler device technique and help patients understand why they need to use them every day (if appropriate). Diabetes MedsChecks can do so much to help people with diabetes.
            BUT we don’t have evidence. The changes from tomorrow will help gather that evidence.

    • Amandarose

      Now I am really angry- the reality is so many community pharmacies are now discount hell holes flogging unproven medications. I do not think it is in their interests to have even more data on their patients to target their exploitation.
      And guess what- many patients visit multiple pharmacies and don’t have a trusting relationship with their pharmacy.
      I have a bit of distain for many of the pharmacies my HMR patients attend as they are incompetent, greedy and do not do the basics like question obvious medication prescribing errors and interactions and dangerous dosing instructions. I do liaise with the if necessary- to double check what the patient been getting filled, to help set up a dose administration aid, bring back the dispensing errors they gave to their customers because the don’t scan. They really don’t like it when I suggest canning the herbal crap they have flogged and ceased medications that don’t have merit. It effects their bottom line.
      Professional clinical pharmacists should not have to play pharmacies to do their job. Sometimes I will suggest a patient swaps pharmacies in the one they attend will not pack DAA’s or deliver medications.

      If they can pass such crap rules that just entrench the greed of the Guild and diminishes the autonomy of HMR pharmacists that don’t have a financial interest in businesses.

  2. Amandarose

    The irony is doctors are writing less scripts? Surely this is at least in some response to HMR’s and the follow on eduction this provides indirectly for their other patients.
    They are subsidising pharmacies for shared risk but the people who would directly be advocating sensible prescribing and quality use of medicines are ignore yet again relegated to a low income for time intensive, expensive to conduct and hard to deliver ( due to caps making working in a pharmacy as well essential greatly reducing flexibility to see patients in a timely manner.
    I am so tired of hoping for sensible change in the corrupt and greedy world of politics and conservative, look after the old boys club political climate.

    I can honestly say for every 10 patients I see about 7 will be ceasing useless medications. Thanks 6CPA for screwing us over YET AGAIN.
    As for Medschecks- I really do think they have a place but they are nothing compared to a HMR and mainly benefit greedy pharmacies like Chemists Warehouse. who don’t have the morals to do them with the right intention.

  3. Philip Smith

    What ever happened to the CW that was churning the med reviews out?
    Is their an audit process on meds checks?
    Are they being abused?

  4. Markus

    I recall the introduction of a cap on HMR services as a result of alleged misuse and overclaiming. I was told by GUILD officials at the time that this was a temporary measure. It seems it is permanent. There was a clear opportunity to remove the cap. The next opportunity is once the eligibility criteria have been reviewed. Then HMRs must be one of the most accountable and transparent programs in 6CPA and as such caps have no further justification (if they in fact ever did).

  5. Bruce ANNABEL

    I fail to see how in an overall sense the additional funding provided by Minister Hunt and taxpayers is bad for the industry, the profession and patients in particular. While I do understand that it was a great pity HMR funding wasn’t expanded (although HMR follow up services funding has been flagged) the additional funding of approximately $47,000 per annum per pharmacy, on average, over the three years is vital. That’s because it helps improve pharmacy viability that has struggled with dispensing incomes and bottom lines being belted by price disclosure during the past four years with the resultant downward pressure on pharmacist wages. Every pharmacist I have spoken with has signed with relief. And furthermore lifting medication management and adherence services funding, where majority of the funding is targeted, incentivises pharmacists to deliver profitable and well remunerated professional services aimed at improving patient health. After all the great majority of pharmacists are employed in the community pharmacy setting and interact with the great majority of pharmacy patients and health consumers. The Guild and the government are to congratulated in that respect and now it’s up to pharmacists to deliver the services, pharmacy owners to build strategies that ensure they do and make the most of the opportunity. Three years will pass quickly and pharmacists have the opportunity to enhance their relevance helping ensure a strong 7CPA 1 July 2020.

    • Big Pharma

      More taxpayer money isn’t bad for the industry. It’s where it’s being spent that is the issue. Remarkable gift if you are an owner. Realise that the ONLY evidence-based medication management service (the HMR) has received nothing and remains stagnant.

    • John Wilks

      With respect the fundamental flaw in these announcements is that dubious evidence-lacking programs such as Medscheck are to be enhanced whilst evidence-based primary care activities such as HMRs are warehoused.

      There are now many dozens of peer-reviewed papers clearly showing the clinical merits and economic benefits of HMRs.

      The many accredited pharmacists who daily conduct HMRs improve the QoL of patients and save the government money.

      It is depressing and dispiriting that the PGA continues to promote one part of the profession to the exclusion of other front line, highly trained medication specialists.

      I attach a link of my submission to the King Review so that you can see what a HMR is, and how the doctors interact with the report.


  6. Pete

    Only 4 staged supply patients covered, what do i do about the other 10 I have. I guess they don’t get staged supply?

    • PharmOwner

      You might have to tell them, “Sorry, the government aren’t willing to fund any more than 4 patients. But you can raise the issue with your local MP”

    • John Wilks

      Yet another clinically incomprehensible part of the 6CPA!

  7. Big Pharma

    Here’s a question for the forum….scenario:
    Say as a result of a HMR an accredited pharmacist ceases several complementary medications that have no documented evidence of benefit, saving the patient a small fortune each month. The GP agrees. The community pharmacy is involved in the “follow-up” whatever that means. What is the pharmacy’s obligation in regards to these products? I’m assuming there is a clear breach of ethics if sales continue despite having a written care plan as well as being paid for “follow-up”?

  8. Amandarose

    I am not so much anti Guild but pro HMR and pro progression and evolvement of the profession. Its really a moot point saying the Guild created HMR’s as the guIld are still the only voice in pharmacy. They have achieved some good negotiations here for businesses such as decent payments for packing. BUT when they lobby for us to be in the retail awards, and encourage low award wages and stifle progression into new paths for different types of business in pharmacy they are doing us all a disservice. They are saying they as pharmacists are also only worth $25 an hr. If our skills are so poorly respected why should pharmacies be paid good money? We are more then a make up shop or perfumery.

    Thanks Guild inventing HMR’s. lts great it has evolved from a perk to subsidise falling renumeration and build relationships with regular patients to a high quality clinical pharmacy service. I also thank the Guild for subsiding my initial accreditation! HMR providers are businesses owners aswell and would be happy to join the Guild and combine our interests as opposed to having our interests completely undermined. Is a HMR provider any more of a competition then the pharmacy around the corner? Is it any competition at all if your not accredited? If you can lobby successfully with your real competitors why not include us? Happy to pay.

  9. Anthony Tassone

    There has been some discussion on this and other forums around whether HMRs should be within the Community Pharmacy Agreement or funded on the Medical Benefits Schedule (MBS), and the level of evidence (real, perceived or otherwise) for different programs.

    it was the intention in the original 6CPA document that a cost-effectiveness assessment would be conducted on the continuing pharmacy programs (that included HMRs and MedsChecks).

    The below is from the agreement document itself (Appendix B note, and Clause 6.1.3 itself: “* Funding for Community Pharmacy Programmes under this Agreement will be subject to a cost-effectiveness assessment as outlined in clause – 6.1.3.”

    “Clause 6.1.3 – The Community Pharmacy Programmes set out in Appendix B will continue from 1 July 2015 until the Minister determines otherwise and will be subject to a cost effectiveness assessment by an independent health technology assessment body (such as the Medical Services Advisory Committee or the PBAC) as determined by the Minister.”

    The 6CPA document is available via:


    The cost effectiveness assessments, to my knowledge, have not been completed.

    Below is an excerpt from the Budget compact recently agreed by the Minister Hunt of the Federal Government and the Pharmacy Guild:

    (the full budget compact is available via:


    “The pharmacy programs will also be redesigned to support the collection of information to allow assessment of the effectiveness of these interventions, and will be funded through a combination of maintaining existing levels of pharmacy program funding, and through an additional investment from the $600 million held in the Contingency Reserve for new and expanded community pharmacy programs.”

    The reason why I point out all this is to help address questions about evidence.

    The Department of Health are undertaking a cost-effectiveness assessment on these programs, and the level of ongoing funding (or not) beyond the 6CPA will be the subject to these assessments. This is why post July 1 there will be additional data collection processes to help enable this cost-effectiveness assessment.

    A service would not be able to be funded under the MBS unless it had been subject to a cost-effectiveness assessment by an independent health technology assessment body (such as the Medical Services Advisory Committee as mentioned above from the relevant clause in the 6CPA document).

    Going forward depending on the outcome of such a cost-effectiveness assessment by an independent health technology assessment body there is the potential for such services to be funded through the MBS.

    However, to my understanding that is very unlikely prior to such a cost-effectiveness assessment being undertaken.

    Anthony Tassone
    President, Pharmacy Guild of Australia (Victorian Branch)

  10. Jarrod McMaugh

    Mark, clearly you’re annoyed at the release of information about the funding of the 6CPA. I wanted to point out a few things about you’ve said that aren’t quite right.

    First, the announcement of the funding and caps of other programs in the 6CPA don’t mean that the HMR caps aren’t being changed. There is a review of the Medicare-side of HMR, and at the end of this review (which is looking at eligibility criteria and patient groups that may require special consideration), the funding for HMR and any caps will be announced. Fair enough people are cynical, but it seems that most people are overlooking the fact that the review is ongoing for this item.

    The other thing I wanted to point out is how you contradict yourself here.

    In your second paragraph, you talk about how community pharmacy has no role in HMR. In your third paragraph you talk about how HMR is a collaborative process.

    It would seem that you don’t think there is a need to collaborate with a patient’s preferred pharmacy, even though this would be the health provider that the majority of patients will see before any other. That doesn’t really add up – how can you have collaboration with an individual about their health and not include all of the health providers relevant to the collaboration?

    I also wanted to point out that your second paragraph is an example of why HMRs aren’t as effective as they should be…. because the impact of ANY intervention occurs over time, and needs to be followed up and implemented correctly. This means that if you think that the moment an HMR has occurred, that all issues are solved, then you’re failing your patients. Clearly the GP needs to know your recommendations, but the pharmacy that sees this patient (again, more regularly than any other health professional) needs to know as well.
    The number of times I’ve had patients who continue to fill prescriptions for ceased medications after an HMR is significant. I’ve had patients on DAAs and we were never informed of changes to their profile, with months passing until the issue is identified.

    The attitude from any accredited pharmacist that they do not need to communicate with the community pharmacy patronised by their client is not only unprofessional, it is dangerous, and fails to meet the QUM principles upon which the HMR services were developed.

    I for one am very happy that there will be a process for review of HMR by the patient’s preferred pharmacy after an HMR has occurred, but it ensures that the pharmacy implements those recommendations, and it also ensures that the patient actually understands the changes.

    • Amandarose

      But it shouldn’t be compulsory because it not always needed, it may not be the wishes of the patient and many people still don’t have a regular pharmacy and don’t need one if they are bight people.
      Another big group of patients do require communication with the pharmacy though- to sort out and investigate issues, repack medication, and share concerns. Sometimes there is nothing that the pharmacy needs to know and it involves confidential information. It should be the patients choice. I always write the pharmacy name and request the doctors fax the medication plan to the pharmacy and myself which is my report plus the doctors comments which is the most useful document for them.
      Other times patients need a Webster pack and don’t have a regular pharmacy so I will find one they like and is close by and will meet there needs such as packing or deliveries.

      so if it is an additional service, and it benefits the patient yes it is worthy of funding and for certain people- such as those with dementia who need extra prompting and encouragement it is great.

      • Jarrod McMaugh

        If someone qualifies for an HMR they must be utilising at least one pharmacy. If they are randomly filling, that’s fine too, but you would be able to have a discussion with them about why having consistent health providers is beneficial to them.

        I would also argue that if someone doesn’t require afollow up on changes/recommendations from an HMR, then perhaps it wasn’t necessary in the first place? Either because their issues where so minor that the GP requested it inapropriately, or because there were no issues or recommendations resulting from the HMR. The logic follows that if they need an HMR, then there would be a need for following up.

        The point on privacy… I get that there are issues that patients want to keep private. Part of the role of the HMR provider is to determine what is or isn’t appropriate to communicate to the rest of their health care team.
        If something is significant enough to communicate to the GP, then it is significant enough to communicate to their pharmacist

        • John Wilks


          Many issues that flow from a HMR are only required to be followed up by the GP – a new HbA1c to verify if a new/changed DM regime is beneficial; TSH review because the patient has started/changed dosing for amiodarone, genetic test to check for single nucleotide polymorphism in compliant pt on warfarin showing poor INR level (pt had CYP2C9*2), lipid review due to a detected poor statin compliance, review patient records to determine duration of use of bisphosphonate and if a ‘holiday’ is required, stool culture to check for C.diff secondary to PPI use, review of falling CrCl in the context of use of metformin/NOACs etc, referral to neuro to determine if pt has amiodarone-induced peripheral neuropathy, need for a BMD DEXA in the context of prolonged PPI use, review Mg levels as pt has cramps and on PPI, dig level review as pt had put spare dig tablets into old Ostelin bottle, serum quetiapine level due to excessive daytime drowsiness (pt was 1.5x>then ULN), ?make aspirin 100mg an alternate day therapy as pt has easy/unprovoked bruising, MTX serum check as pt was storing MTX in old 5mg warfarin bottle, pt exhibiting STML secondary to ventriculoperitoneal shunt and hence need for MMSE etc etc etc. (This is a brief skim/recollection from recent reviews)

          Naturally these issues are included in the HMR report to the pharmacy so that the community pharmacist is aware of the issues. This is an important part of the cycle of care, at an awareness level, but as to follow-up by the pharmacist, I see little clinical role other than asking about this or that result.

          Am I a community pharmacist? I was for 23 years – sold 7 years ago. I have been an accredited HMR/RMMR pharmacist for 20 years.

          • Jarrod McMaugh

            Lovely list John.perhspd I could attempt to make my responses more emotive too by padding them out with all of the clinical issues I come across and attempt to fix on a daily basis…. I won’t because it doesn’t change the point I am making.

            That is, the impact of an HMR doesn’t end with your report to the GP….. Except for the reviewing pharmacist.

            For the patient, the GP, and the pharmacist they see regularly, the management of that patients health and care is ongoing.

            If the GP is swamped, or doesn’t see the relevance of your recommendations, or the patient doesn’t follow up with them in a timely manner, or they don’t understand the importance of anything you do, then who is looking after that.

            Getting back to your anecdotes, can you tell me you’ve never had a recommendation overlooked? Never had a patient whom you’ve reviewed before that still has an issue(s) that you made recommendations on before?

            I know I have.

            The fact that there are a cadre of vocal accredited pharmacists who do not understand (or refuse to acknowledge) the importance of the involvement of a patient’s preferred pharmacist in their care smacks of arrogance…. And given that I’m the most arrogant person I know, it’s saying a lot that I would raise that as an issue.

            There should be no reason that a pharmacist providing HMR services to a patient should choose not involve thr patients pharmacist. Not doing so, in my opinion, is professional misconduct.

          • John Wilks

            Might I suggest a little less invective tone? Courtesy is the usual hallmark of civilized dialogue.

            To clarify: My examples were not anecdotes, which are defined both by the Oxford and the Merriam-Webster as “A short amusing or interesting story about a real incident or person.” or “usually short narrative of an interesting, amusing, or biographical incident.”

            Rather they were examples of clinical intervention by me arising from a HMR that did not involve the community pharmacist. It involved the GP/patient +/- a specialist. That statement is simply a fact, not a criticism of anyone or their professional role, least of all the community pharmacist. As mentioned previously I was one for 23 years.

            Undoubtedly the CP helps enormously in patient care, as I did when a CP. but the HMR is a direct referral from the GP to a clinical specialist (accredited pharmacist), in the same way as a GP writes a referral to a cardiologist etc.

            As to recommendations being “overlooked”, the GPs I work with are very expansive in their replies. Are all my suggested accepted? No, as the GP has a deeper knowledge of the patient’s pmhx etc. I have the good fortune of seeing many patients for the 4th or 5th time,sometimes yearly, sometimes only a few months apart (if they have been hospitalized after the first visit).

            In discussing the earlier review, the patient becomes a second source of information as to why a med was not deleted/reduced/increased , or a test not done etc etc. Hence I would have to answer ‘no’ to your question about recommendations being overlooked.

            Instead, in my experience, the recommendation(s) are not accepted by the GP, as is his/her prerogative, or on many occasions, the recommendations are deferred to a specialist for further consideration.

            As to your statement that there exists a “cadre of vocal accredited pharmacists who do not understand (or refuse to acknowledge) the importance of the involvement of a patient’s preferred pharmacist in their care smacks of arrogance” , might I respectfully suggest that this is tonally inappropriate and factually wrong.

            The word ‘cadre’ is defined by the Cambridge dictionary as “a small group of trained people who form the basic unit of a military, political, or business organization.” A less pejorative word should be used I think.

            And to describe accredited pharmacist’s as exhibiting “arrogance” is an unpleasant word at best.

            Your closing paragraph states: “There should be no reason that a pharmacist providing HMR services to a patient should choose not involve thr patients pharmacist. Not doing so, in my opinion, is professional misconduct.”

            Again, the accusation of potential “professional misconduct” offends the purpose of this forum, lacks decorum, implies an egregious level of professional behaviour by a HMR pharmacist and is factually wrong. Normally “professional misconduct” is an assessment only made by the Pharmacy Board.

            Your last statement also appears to suggests you are unaware that a copy of the HMR is sent to the patient’s CP. I did note this point in my entry “Naturally these issues are included in the HMR report to the pharmacy so that the community pharmacist is aware of the issues.”

          • Jarrod McMaugh

            Quite happy with the tone, because it’s appropriate

            While you’re looking up the dictionary, look in to “anecdotal evidence” – that’s what you provided, and the reason you did it was completely cynical, since you were attempting to display why the routine you do 20 times a month is more important than what a pharmacist who works in community or hospital setting does every day.

            The majority of pharmacists who I know that are accredited work in community or hospital settings, and they understand the importance of communicating adequately with those health professionals who regularly interact with the patient.

            Of the HMR communication that I have received and viewed, the best always comes from pharmacists who work in community or hospital part time or full time.

            When I have seen poor communication, every time it had been from a pharmacist who primarily does HMR as their primary role (I look forward to someone intentionally taking this to mean that all pharmacies who do HMR as their primary role are poor communicators)

            These communications have been dismissive of the community pharmacists capacity or ethics, accusatory in nature, or in some cases, containing nothing more than “on this date an HMR was provided to patient X”

            The ironic thing is that the accreditation process places a strong emphasis on how to communicate with GPs in order to not offend them or their clinical decisions, yet zero emphasis is placed on extending this courtesy to pharmacists.

            Again, I’ll reiterate my point that there is a small cadre of pharmacists who have accreditation who believe that communicating with pharmacists is beneath them. It is not possible to make a valid argument for not communicating with a patient’s pharmacist, and while the process of HMR requires this, the standard in a small (but significant) number of cases is sub standard.

            I’m going to balance these sentiments with another – the poor experiences I have had (or have had related to me by other pharmacists) are a small percentage of the total experirnce. I am not making a wholesale criticism of accredited pharmacists, especially since they are generally excellent pharmacists with a vital role. My comments are driven by the fact that I demand excellence from my own practice and those around me…. So when I see behaviour or opinions that deserve criticism, then I will deliver it.

          • Amandarose

            At the end of the day I personally appreciate all the good pharmacists in retail do. I am even a semi Guild fan as I appr crate people who fight for their industry especially good communicators like yourself and Anthony. Thanks for those achievements that protects and industry that seems to be under fire.
            I just don’t like a few aspects that have a bad impact on me- such as their attiditude towards HMR’s and a perceived ownership of patients. The wages issues is also irritating as it devalues our professional standing.
            My issue with follow ups is they will not be needed for all HMR’s and a pharmacy should not be forced to be linked to every review. It’s not right and it’s a waste of money. I am hoping the intent is for this to be optional for those best suited to it but knowing the Guild and their relentless push for a slice of every pie they will try there best to get their claws into funding for other people’s work.
            I initiated Webster packs and deliveries for a patient with multiple issues,potiential drug side effects and poor compliance that will need negoatiion and follow up with the pharmacy and doctor and patient. This case would be suitable for pharmacy follow up and I can see a role here is follow up as she sees multiple GP’s at a clinic and has fallen through the cracks and the pharmacy could play an important roll here.
            But another example- excellent involved GP sent referral as patient has a drug related adverse effects her fears and wants it looked into ( muscle weakness in legs) – in this case a patient was diagnosed with motor neurone. GP questions this and wants information on drug causes for neuropathy. Information provided to GP and patient who has a PHD at is perfectly intelligent. No regular pharmacy and he travels a lot for work. We keep in touch via email and the suspect statin was ceased and his symptoms went away. He went though options with his GP and NNT and NNH data and other options and they decide for now he will try lifestyle measures to reduce his cholesterol. He gets second oppinion for another neurologist and his results are good and he agrees his symptoms were drug related.
            IN this example I would be annoyed if a pharmacy was paid to “follow this up” as they don’t have a roll here and the selection would be random as he doesn’t have a pharmacy relationship.
            i will be so furious is this is compulsory and they use their voice to drown out ours and treat all these services like compensation for dispensary losses. It’s unclear what exactly will happen- So I will vanely hope common sense will prevail and the cap will be lifted to something realistic and these will be valuable additions for pharmacies who have much to sort out as a result of HMR’s for certain patients.

          • Jarrod McMaugh

            A couple of things:
            1) I don’t represent the guild in any way. I often (but not always) support their intentions, and I am now a member, but I don’t speak for the.

            I have often agreed with them on a lot of issues for years before I became a member or even had any expectation of being in that position. One of the issues I’ve always felt very strongly about is the way the Guild gets blamed for all types of issues in pharmacy – ironic actually because people clearly expect the guild to be taking the lead if they think they are responsible for all the problems.

            That got off topic….

            2) of the small number of accredited pharmacists who I feel give the remainder a bad reputation, ownership of patients is one of the biggest complaints I have of them.

            3) of the accredited pharmacists, community pharmacists, and owners stereotypes, I feel they are all generated by the behaviour of small numbers. A shame really. Would be great if there were few assumptions made in every direction.

            I think one thing that is consistent in my comments on most things on here is that I try and cut through the assumptions people make and try to look for the optimistic outcome.

            On this topic I know as much as everyone else – which is the summary details. Most people have jumped to conclusions about HMR but haven’t focussed on the other important (and family more common) issues in the document. Personally I think it’s worth waiting to see facts before complaining.

            4) on the follow ups – I’m expecting there will be criteria…. There is for everything else. Again, awaiting details, but remaining positive until I see them.

            While on the topic … I would point out that I am glad caps on HMR and MedsCheck exist (although I agree they are too low)

            I’ve witnessed first hand the rotting and manipulation of the process. I’ve seen doctors paid to generate referrals. I’ve had to make complaints to Medicare and the medical board when patients weren’t given a choice of provider. I’ve seen accredited Pharmacists utilise the blind faith people have for their doctors to convince them to change pharmacies. I’ve seen the system manipulated to generate enormous numbers of HMRs in a very small time frame.

            I complained bitterly about this issue, and if it lead to the caps, then I feel this is a good outcome. Believe me when I say I am of the opinion that accredited pharmacists are entirely responsible for the caps being implemented, even though the number of them acting in this manner was small. 1 bad apple can ruin it for everyone…. And while 99% are above reproach, some were very bad apples indeed.

          • Amandarose

            I don’t have a problem with caps, I just think they should be capped at what a reasonable person can do well.
            Same with capping the number of scripts that one person can safely dispense or how many interventions can be claimed.

          • Jarrod McMaugh

            I can only agree with you Amanda – having caps has been useful to address the rorting that occurred, but at this point the caps have become a noose. I support loosening this noose, but I also worry about a return of predatory behaviors.

            It really only takes a handful of practitioners to ruin things for everyone else. Just look at AMI/MWI and afterhours home visits for impact on the reputation of doctors. Look at the number of pharmacy brands who industrialised MedsChecks before there were caps here (there was only 1 brand, btw).

            For the record, interventions are functionally capped – there is a ratio of PBS scripts to interventions – beyond a certain percentage (I believe 4-5%), the return on CIs diminishes rapidly. My pharmacy records a lot of CIs, and we regularly hit this threshold, but I ask my pharmacists to continue to record them (and to do more than 10 Medschecks a month), because the point isn’t the remuneration (as nice as that is to cover wages), but to ensure practice change (through recording of relevant information), and to discover issues with a patient’s understanding of their medications.

          • Big Pharma

            Manipulation and rorting occurs in every area of life. It is not an excuse to destroy a program/industry. Appropriate caps and audits were always the answer. Good to see you reporting fraudulent behaviour.

            Why not cap the number of PBS scripts that can be dispensed in a month per pharmacy due to those rorting safety net procedures/supplies? Why not remove pseudoephedrine supply from pharmacies due to some encouraging diversion? Bad apples are everywhere. Doesn’t mean ridiculous solutions are the answer

          • Jarrod McMaugh

            I’m waiting to find out if you were accredited at the time of caps, and I’m considering relating the two rorts that I know occured (one I witnessed first hand, one i was exposed to visit a colleague who witnessed it first hand)

            PS odd that you would use pseudoephedrine to made your point, since caps on supply is the functional outcome of the pseudostop program.

          • Debbie Rigby

            I think that the trigger for a follow-up by the community pharmacy should be indicated by the accredited pharmacist completing the HMR and the referring GP i.e. in the medication management plan. You are correct, not every HMR requires a follow-up. Follow-up may be required and may well be critical when addressing behaviour change e.g improving inhaler device technique and adherence. During the HMR, inhaler device technique can be assessed and improved, together with written instructions; but it is critical that the patient’s technique is further assessed at the next dispensing and on a regular basis.

          • Big Pharma

            Where are these accredited pharmacists that do HMRs as their primary role? I would think starvation would have killed them off since the 2014 moratorium

          • Big Pharma

            Well said John. A good example of common sense.

          • Big Pharma

            Got nothing to do with arrogance. Got nothing to do with the importance of the patient’s community pharmacist. Has more to do with common sense.

            Unless the community pharmacy has a written MMP from the GP following the review then a “follow-up” is utterly useless and a waste of taxpayer dollars. Well, even if a MMP is provided, as long as scripts are written accurately and the patient is competent, the follow-up is also a waste of time.

          • Jarrod McMaugh

            Mark, while I’m not wanting to suggest that patients aren’t capable of looking after their own health, but a very large number of people who require HMR, need it due to their poor health literacy. Assuming that performing an HMR somehow fixes this is unrealistic.

            The majority of HMRs are for patients who have medications regimens where the doctor has gotten themselves into a prescribing mess, or the patient is having trouble complying with the prescribed doses.

            For these patients, the follow up will be very valubale, because the issues that are arising in these situations aren’t solved with a single report between an accredited pharmacist and a GP…. especially when the issue has been poor prescribing by the GP.

        • Big Pharma

          You would argue that if a follow-up is not required by the community pharmacist then the HMR wasn’t necessary in the first place?? Really…wow! That makes absolutely no sense. I could sit here and explain what exactly is involved in a clinical medication review but I feel it would fall on deaf ears.

          Medication changes are made frequently on the wards of the hospital and often the patient is not made aware of these changes. The community is no different. Doses adjusted for renal function etc. Not always applicable to go through the changes of a metformin dose reduction in a dementia patient with CRF who has a webster pack. Just make the appropriate changes.

          • Jarrod McMaugh

            Mark, you are still not seeing the patient as the centre of care, or in the case of a dementia patient, perhaps their primary carer.

            There is ALWAYS a need for information to be imparted to the patient/carer, and it is ALWAYS important to follow this up, regularly.

            This is the reason that inhaler technique requires regular review, because people introduce errors in their process. The same goes for medications of all kinds, especially when any suggested changes have been made. Human nature is such that people will do whatever is simplest for them… and it is also such that when you make a change, people will make errors when implementing these changes.

            For instance, people take their medications at a specific time of day, and develop a routine where they don’t even think about it. Then a pharmacist notices that the time they are taking their medication is not optimal for some reason (lets say simvastatin in the morning), and recommends a change so that they get the best effect from it. Next thing you know, their LDL cholesterol starts to rise and it turns out that they now understand that evening dosing will work better, but they just can’t seem to remember to take it at night because this isn’t in their routine.

            When a potential intervention is identified (either in a community setting, in a hospital setting, or during a medication review), the most important part of acting on this identified issue is not how or when to make a change, but whether a change is in the best interest of a patient. IF the change is implemented, there needs to be a plan to follow up and reinforce the change with the patient, so that they don’t have a poorer outcome.

            I’ve been involved with a lot of medication reviews, and I’ve been involved with a lot of chart reviews, and the difference between the two is that there is someone paid to implement changes to charted medications, while an independent patient is looking after changes on their own. When I see an issue with medication that is charted, I have a lot of confidence that any recommended change can actually be implemented effectively. When I see a medication issue with a patient who looks after their own medications, or care for someone else, I am very careful to ensure that any recommended changes can actually be achieved.

            Now, knowing that human nature is a major factor in the success of any intervention with a patient’s health, I ask you how a person who has received an HMR, then sees their GP a few weeks (or even months) later to discuss any recommendations or changes, will be able to effectively participate in the decisions about their health and successfully implement change?

            Let’s not forget that the buck stops not with the HMR pharmacist, not with the GP, but with the patient. This individual needs to be able to understand what changes have been made, why they have been made, and then actually carry on in the way that recommendations/prescribing direct them to. Then consider that the pharmacy, who may not even know that the patient has participated in an HMR, is presented with a prescription for a medication that has been ceased/increased/reduced/schedule changed. The pharmacist dispenses the medication as per the existing instructions (because as far as they are aware, this is still correct), and the patient goes home with their medication labelled with the instructions they’ve always received.

            At this point, do you think the patient knows that their pharmacist may not have been included yet (or at all) in the discussion on their medications? As far as they’re aware, they are part of their health care team – they choose to see this pharmacist monthly (perhaps more, perhaps less), in the majority of cases they see this pharmacist more often than they see their GP – definitely more often than they see an accredited pharmacist.

            So with the assumption that their pharmacist knows about their health care, the patient goes home with their medication, and continues to do what they’ve always done, regardless of the GP’s records or the HMR pharmacists suggestions. This could continue for a few dispensings, depending on if the pharmacist ever receives any communication about the HMR…. or even later when the GP reissues a new script with new directions….

            Now, what the new part of the HMR is intended to do is to ensure that everyone is on the same page – there has been mention of “fragmentation of care” in providing this part of the service, which is an interesting term since the purpose is to reduce fragmentation by including all pieces of the patients medical team – GP, Pharmacist, and Reviewer.

            At what point is someone so cynical and jaded that they believe that the inclusion of one of the patient’s health care team (perhaps the one they see more than any other) is inappropriate? When does one health professional think it is unnecessary to communicate with another about a patient’s health?

            It is really amazing to me that there are people commenting on this story who are so against community pharmacists that they think talking to one is unnecessary and think that doing so is for no purpose.

          • Big Pharma

            So what is more important…the HMR or the follow-up? There is claimed to be not enough money for evidence based clinical services yet plenty for the frills surrounding the actual work. On the surface the new part of the HMR is nothing more than a compensation scheme now direct referrals are in existence.
            Rural areas no longer have access to HMRs because of isolation, which were available before the capping. The benefits of a HMR itself would far outweigh the benefits of a “follow-up”. No one is disputing the necessity to communicate. The debate is whether new add-on services with no evidence should be implemented when evidence-based services are shelved. Fixing the HMR program itself is far more beneficial than funding bells and whistles and should be done as a matter of urgency!

      • Debbie Rigby

        I agree that follow-up is not always necessary after HMRs.

    • Big Pharma

      I’ll be proven wrong when/if changes to the HMR cap occur. Yes cynicism is a trait of most clinical pharmacists….the PGA can be blamed for that one.

      An HMR is a collaborative process. A copy of the HMR report is sent to the patient’s community pharmacy. My question is what can you do with it other than read it. Furthermore, I can tell you from experience there are some community pharmacies that refuse the report. Define preferred pharmacy..many patient’s don’t have a preferred pharmacy.

      The impact of any intervention occurs over time? Clearly you haven’t worked in the hospital system where the impact can be instant. Are you suggesting the GP is unable to read, assess and discuss the report and then implement the changes? Come on now!! The pharmacy can be made aware of the changes at the time the patient presents to the pharmacy with the changes.

      Patient’s filling ceased medication scripts does not imply an in-house pharmacy follow-up is required or even that the community pharmacy will pick up this error…this can happen at any time along the patient’s health continuum. Maybe we should have a funded in-house community pharmacy review each time the patient sees their Cardiologist?

      Let’s say for example a medication cessation is recommended by an accredited pharmacist because of X, Y, Z. The GP feels cessation is not necessary due to A, B, C and wishes to continue. The HMR report, which the community pharmacy has, suggests cessation. Does the community pharmacy then contact the GP to question the next time this script is presented? As I said….what is the follow-up? What is the benefit? Unless the pharmacy is aware of the final changes to therapy how will they ensure these changes are made? Does the community pharmacy contact the GP to put together a MMP? Doubtful. Plenty of flaws in this follow-up scheme. UNLESS of course the accredited pharmacist initiates/recommends the follow-up (inhaler technique reinforcement etc).

      • Jarrod McMaugh

        Mark, can I ask if you currently do any shifts in community pharmacy? I’m curious before I address this response.

        • Big Pharma

          Been there done that. I am hospital ward based. Does this change things?

          • Jarrod McMaugh

            The reason I ask is because your response above seems to.suggest you don’t understand how community pharmacy operates.

            One the point you make above is this

            “What is the follow up? What is the benefit? Unless the phaacy is aware of the final changes to therapy how will they ensure the changes will be made?”

            To this I have to say “what the fuck have I been speaking about this whole time?!!”

            As a community pharmacist I see my patients more often than they see their GP. 80-85% of my patients are regulars. There is very little doubt that myself and my dispensary manager and my services manager and my compounding pharmacist are their preferred pharmacist.

            Our day is spent talking with our patients and their GPs. We refer back and forth all day long, and we generate HMRs for another pharmacist we like working with who is not only an excellent accredited phsaxist, bit comes to speak with us about our patients after he has done a review. He locums with us as well (although he had been too busy lately to take shifts)

            When he comes in, he’ll discuss issues we need to look out for, will make notes in the patients records for us to take note of when we are consulting with the patient, and will let us know what recommendations he made to the doctor.

            Due to this collaborative effort from our accredited pharmacist, we are able to keep an eye out for the recommended changes…. And in a (scarily) large number of cases, the GP does not always implement simple or significant recommendations.

            We work in an environment where every day we are talking with our patients, answering their questions, educating them, being educated by then, and identifying issues that are important to their care.

            We already do the role that has been introduced… Every day we follow up on HMR recommendations, referral we make, and advice we give, to ensure the patient gets the best outcome.

            Now I understand that accredited pharmacists are cynical and frustrated with the system, but perhaps if you worked in the kind of collaborative community pharmacy you’ll find in my group or similar groups, you’d understand that the community pharmacy is as important to the patients outcomes as their GP, allied health, and accredited pharmacist. The idea that we should be excluded because you feel were getting paid to do nothing and have no role or impact is not only insulting and a discredit to your colleagues, it’s a discredit to yourself in that I believe you’ve never experienced the community pharmacy settings the way it is supposed to be experienced/delivered.

            I have one more question for you – were you accredited at the time the caps were implemented? I’m interested to see if you ever saw the behaviour (of accredited pharmacists, about 4 that I know of, but I believe 20ish totsl) that made the caps essential.

          • Debbie Rigby

            Jarrod you describe best practice and it’s what you are doing. But to be fair, it is not what is done consistently across the 5500 pharmacies in Australia. I work collaboratively with community pharmacies with my HMRs. Some are very interested and proactive in documentation and follow-up, including back to me. But others either won’t accept the report and don’t see that follow-up is their responsibility. Hopefully the proposed funding for follow-up will improve that, for the benefit of patients.

          • Big Pharma

            Depends how the “follow-up” is implemented, the criteria for a patient to require a follow-up and if audits are put in place. Otherwise it could very easily be another tick box exercise with no accountability.

          • Jarrod McMaugh

            You know, I actually see this practice very often – most when the pharmacist who did the review works in the pharmacy where the patient has their primary care provided.

            It’s not uncommon as far as I can tell

          • Big Pharma

            I understand very well how community pharmacy works. As I said…been there, done that. There is a significant disconnect between the community pharmacy and medical centres in MOST cases. The knowledge of a patients medical history is lacking in MOST cases. I am very skeptical that “follow-up” will occur appropriately in MOST cases. I applaud the way you have set up your pharmacy, however I can tell you this is not the norm.
            I’m sorry your locum has been unable to take shifts as he has been busy. Whatever relevance that has I do not know.
            I have been accredited for a decade. Yes, I was operating when the caps were implemented and operating fulltime. I serviced, out of my own pocket, some of the most isolated rural communities in the country and saved the taxpayer a fortune. Personally, I was unaware and never exposed to any rorting. Were caps required…possibly. To this extent…not a chance. If, as you say, only 20 pharmacists across the country were operating inappropriately and this lead to a proposed moratorium then that is beyond a joke. An audit could have reversed and recovered this money within weeks…now this was essential. The PGA was the only professional body privy to this information and chose to sit on their hands and watch funding dry out rather than resolve the problem.
            Yes, I am beyond frustrated. News that non-evidence based programs are being created and expanded while the only program with evidence gets shelved is always going to create frustration. Have you ever worked extensively on hospital wards? If you had you would understand just how beneficial the HMR program is, the money it saves and the lives that are improved as a result.

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