Amcal to move into pathology screenings

Amcal + shopfront

Amcal is set to offer pathology health screenings in a bid to capture ‘disengaged’ people at risk of health problems

Sigma has announced that it will offer pathology health screenings throughout its Amcal Pharmacy network from June 26, 2017.

In step with Health Minister Greg Hunt’s recently announced focus on preventative health, Sigma plans to provide easy access to Pathology Health Screening and encourage Australians – especially those at risk of chronic diseases – to proactively participate in early detection and wellness screening.

“Preventative health is a focus of the Turnbull Government and is a central part of my National Health Plan.” Health Minister Greg Hunt said earlier this year.

Sigma Pathology Health Screening will be provided in accordance with best practice by SmartHealth utilising their network of 1,500 accredited participating collection centres and laboratories throughout Australia.

Amcal Senior Pharmacist James Nevile says the health screening service will benefit members of the community who are currently disengaged with the traditional healthcare system.

“We recognise the important role that pharmacists play in the Australian healthcare system and are committed to working collaboratively with GPs and other allied healthcare professionals to deliver integrated health care solutions to the community that result in improved health outcomes,” Mr Nevile says.

“In health care, it is essential that patients are the central focus, and our health screening services have been designed to engage or re-engage patients with their GP and the wider health care system united by the common goal of improving health outcomes.”

As part of the Pathology Health Screening Service, Amcal will offer clinical bundles for health screening purposes to customers who meet the criteria. Sigma screenings includes diabetes, heart, kidney, fatigue, vitamin D deficiency and general health and wellbeing bundles.

The tests on offer have been selected in collaboration with SmartHealth’s Pathologist to limit the risk of over screening or unnecessary testing, and to provide patients with the health information they would like to see prior to visiting their GP.

“We believe that GPs and specialists are the most appropriate and qualified to explain and discuss abnormal/out of range pathology results with patients,” says Mr Nevile.

“For this reason, and as with all Sigma’s health screening initiatives, Amcal pharmacists will refer patients to their GP’s and specialist for follow up as appropriate.

“The feedback received from pharmacists and patients has been overwhelmingly positive. Amcal is committed to a collaborative working relationship with all health professionals and health organisations to ensure the Australian public can access effective and efficient health care solutions.”

Sigma says it will continue to invest in innovative health care solutions that directly address the needs of Australian pharmacy patrons.

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  1. There are many key questions that need to be answered about this initiative:

    1. What is the justification for the screening tests offered in the “clinical bundles” including diabetes, heart, kidney, fatigue, vitamin D deficiency and general health and wellbeing bundles?
    2. What are the “criteria” used to select customers for these tests and on what evidence? For example, the RCPA recommends that vitamin D testing is not conducted or recommended as routine screening:
    3. What is the evidence that this screening provides “effective health outcomes” and what about the harm produced from investigating dubious or spurious “positive” results?
    4. The cost to consumers is considerable compared to MBS fees, for example: $219.50 charged for general health screening; $149.50 for fatigue screening and $89.50 for Vitamin D check; how is this justified and what percentage goes to the pharmacist?
    5. Is this project approved by the RCPA?

    A number of other concerns have been raised in the discussion about this initiative on Aus Doc:

    For example, informed consent – will pharmacists tell consumers these tests are available via their GP (if thought to be indicated) for no cost (if bulk-billed), or a much smaller cost (if they have a co-payment)?

    Also, medico-legal responsibility – some GPs have suggested that if a pharmacist ordered these tests and then referred the patient to their GP with abnormal results, they will explain to the patient that the pharmacist is medico-legally responsible and they will send the patient back to the pharmacy to be sorted out.

    A response from Amcal &/or Sonic to these issues would be appreciated.

    • Jarrod McMaugh

      Yes the pharmacist will be medicolegally responsible for the pathology requests ordered, just as they are for filling prescriptions when these are received from a doctor.

      I would suggest that a doctor that refused to discuss results from any kind of validated investigation – regardless of the source – for any reason other than on clinical grounds (ie who would agree to interpret results of iridology…) would be committing an act of professional misconduct.

      Would it be acceptable for a specialist to refuse to interpret the results of pathology for a patient who has been referred to them, and instead re-order them? Would it be acceptable for the reverse to occur? Would a GP be behaving in an acceptable manner if they refused to receive a patient’s discharge information after being in hospital just because the GP wasn’t involved in the patient’s admission to hospital? Yet it is acceptable for a GP to publicly claim they would refuse to even look at results just because a pharmacist (a qualified health professional regulated under AHPRA) ordered them?

      I think there is a major attitudinal issue with some portions of the medical fraternity. Pharmacists are health professionals with qualifications that are far broader than pharmacology, and training that is far broader than the implementation of the PBS. For doctors to continually claim that pharmacists are unqualified/unethical/etc just because they are pharmacists is unacceptable.

      With regards to Ken’s specific questions, can I ask you, if a doctor was offering these particular pathology requests at these prices, would your opinion on their appropriateness be the same? If yes (and I can see some points that would still justify debate) that’s great, but how about we limit the criticism to these points rather than “because it’s a pharmacist doing it”

      I note that you refer to the guidelines on routine screening for vitamin D…. yet there isn’t any mention of these services being offered wholesale to every person who walks through a pharmacy’s door. Pharmacists are very capable of eliciting a history, along with assessing a patients presenting signs and symptoms, that would allow them to make a clinical judgement as to the appropriateness of requesting a pathology test. I think it is not justified to assume that these tests would be ordered (and accepted by patients at private prices) broadly to every patient regardless of perceived or clinical need.

      I have 2 point-of-care-testing options in my pharmacy that I use from time to time – Afinion Alere (HbA1c and cholesterol panel) and hemocue (haemoglobin). If these were being utilised for routine screening, then I would be offering these tests about 50-60 times a day. The reality is, I have offered HbA1c roughly 30 times in 6 months, total cholesterol about 100 times, and haemoglobin about 5 times (and each of these showed that the patient did not need the iron supplement they determined they should be buying, saving them money and constipation in the process).

      The use of these screening options are not applied without prejudice for the patient’s clinical presentation. Assuming that they would be isn’t justified (in my opinion), and certainly isn’t backed up by any evidence of this kind of behaviour existing in the pharmacy sector.

      • First, I accept that some of the concerns expressed by my GP colleagues relate to turf war concerns rather than the underlying issues.

        Second, having worked with pharmacists all my professional life, I respect their training, competence and professionalism, especially with respect to medication management.

        Third, many Australians are unaware they have modifiable disease risk factors such as high blood pressure, high cholesterol and obesity; either because they are not seeing GPs, or these risk factors are not being assessed. So, there is an important role for allied health professionals to engage in preventative health activities.

        My main concern (as a consumer advocate and public health physician) is the commercially driven nature of this initiative, the cost to consumers and the questionable rationale for some of the test panels (clinical bundles) promoted.

        I’d like to see the screening questionnaire said to be used by pharmacists and learn more about the accredited training they are said to be required to undergo before participating in this scheme.

        Finally, I’m especially uncomfortable about Sonic providing pathology testing to the alternative practitioners such as Naturopaths, Homeopaths and Chiropractors. I suspect that abnormal results are going to be given inappropriate interpretations by many of these practitioners. There are already questionable laboratory tests being ordered by such practitioners and used to justify non-evidenced based treatment, e.g.

        • Jarrod McMaugh

          One of the reasons I like discussing these issues with you Ken is that your responses are reasoned, and you are passionate about your purpose.

          With regards to the issue of “Turf War” – I would contend that 95% of the comments that have appeared on the AusDoc article are driven by this. A good portion are also driven by a lack of knowledge of the capacity of pharmacists, or a belief that only doctors understand medicine. I would also contend that while it is important to note the discomfort of existing practitioners for any kind of competition, this is not a valid reason to block progress.

          I agree with your concern about Sonic expressed in the last paragraph. (although I’m really intrigued about having my morphology compared to the morphology of flowers in order to determine my emotional state… seems to be ground-breaking stuff in so much that it’s digging a massive pit into the credibility of the practitioner offering it). Despite this, it’s no more relevant to the pathology services being offered to AMCAL pharmacists, than it is to the pathology services being offered to doctors. It’s inconsistent to have an issue with Sonic only in the context of services provided to practitioners who aren’t doctors.

          With regards to the “commercially driven nature” of the initiative, and perhaps health in a wider sense, I think we’ll have a philosophical difference in opinion.

          The reality is, health and medicine is a commercial industry, wherein the commodities (both physical and cognitive) that are traded have a high level of complexity, and the consumer is at particular risk due to a relatively poor understanding of the nature, quality, necessity, and relevance of the range of commodities available to them.

          Society respects health professionals not only because they understand these complexities, but because in the majority of cases, we place greater importance on consumer benefit over financial gain. This is the true nature of a health care business, and it is the reason why a pharmacy selling a physical product (or not) to a patient has the same potential for conflict of interest as a doctor selling a cognitive product (or not) to a patient.

          The extra layer of complexity here is subsidised health-care provision. As I stated earlier, from a purely commercial point of view, doctors have a distinct advantage due to the ability to access subsidies that pay for the cognitive products they provide to a consumer. Doctors aren’t providing any service akin to the ones from AMCAL for free…. they just aren’t charging the patient for them.

          In my opinion, whether the service is commercial or not isn’t really relevant, since almost all health care is commercially driven (the type of car driven by a surgeon I recently utilised is the n=1 evidence I will provide to back up this point). Again, this isn’t a bad or a good thing, so long as the provision of the product or service in question is guided by the practitioners clinical opinion that it is relevant and useful.

          I guess my point is, the reason (or not) to criticise the provision of any health intervention should be based on those points I raised earlier – what is the nature, quality, necessity, and relevance of the service? Who is providing the service, and at what price, should be relevant only to specific cases where those points aren’t being met.

          I think we’d both be horrified if we saw a HCP supporting the service you linked to – we know that it’s garbage and no one should be endorsing it.

          The question is, if we saw a HCP providing a validated service involving pathology in order to determine the correct course of action for a person who has clinically relevant signs and symptoms indicative of a modifiable chronic disease, would we be happy that this individual is being provided with appropriate help, or would we say “well, that depends on who the HCP is?”

          • 29/06/2017

            Hi Jarrod, Given prior discussion with a consumer about the cost, potential benefits and risks (and informed consent), I’m happy with any well trained HCP ordering appropriate pathology tests to determine the correct course of action for a person who has clinically relevant signs and symptoms indicative of a modifiable chronic disease.

            But, if this is to be done properly, it needs relevant education (and monitoring): hence my interest in Sonic’s screening questionnaire and the accredited training mentioned. I’d like to be reassured that this is appropriate, for example, is the education provided about Vitamin D screening in accord with “Choosing Wisely” recommendations:

            And are we confident that other HCP targeted by Sonic such as Naturopaths, Homeopaths and Chiropractors will use these results appropriately given their very different training, philosophy and exposure to more questionable tests?

    • Jarrod McMaugh

      One point I failed to mention when discussing my POCT devices that addresses one of your questions – “will pharmacists tell consumers these tests are available via their GP (if thought to be indicated) for no cost (if bulk-billed), or a much smaller cost (if they have a co-payment)”

      This is the first part of every conversation I have with a patient regarding many of the services I offer.

      The funny thing is, when it comes to a purely commercial examination of this situation, GPs have a perverse advantage in that they gain business due to their access to government subsidy.

      I could provide a set of pathology tests and/or POCT tests, followed by a vaccination for influenza, and perhaps a medical certificate if appropriate (lets say there was some unrelated issue that was relevant to missing a day of work). Alternatively, I could refer this person for each of these to be provided free of charge (or heavily subsidised) by someone who – in a commercial sense – is a direct competitor….. and my moral and ethical obligaiton is to ensure that this person not only knows that I have a competitor who has a distinct advantage on price due to government subsidy, but to encourage them to use this option.

      Now clearly a pharmacist is more than happy to do this (just like we often discourage a patient from purchasing unnecessary medications), because we are driven by the best interests of the patient. For this reason, it is particularly disheartening to always be subjected to criticism from doctors about conflict of interest etc when the only conflict a pharmacist has is the same as a GPs…. ensuring a patient returns by providing a valued and valuable service.

      /end rant…

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