An ‘anachronism that needs to go.’

Frequent critic of the community pharmacy sector Dr Evan Ackermann has taken to MJA InSight to encourage longer script durations – saying the main obstacle is pharmacy itself

But the Pharmacy Guild’s Anthony Tassone has hit back at the claims, telling the AJP that Dr Ackermann is “cherry picking” support for his argument.

In an opinion piece titled “Exorbitant costs of routine medication repeats,” Dr Ackermann writes that “it is time to cease an anomaly which increases costs and inconveniences patients without any health benefit”.

“The Pharmaceutical Benefits Scheme (PBS) requirement that dictates monthly medication dispensing for many long-term health conditions is an anachronism that needs to go.”

Dr Ackermann says that having to visit a pharmacy regularly for medication repeats has been described by patients and carers as a “recurring hassle”.

He cites a number of reviews which find “little support” for monthly medication supply, and says that longer script lengths have been linked to improved medicines adherence and lower costs for patients.

“With these medications, there is overwhelming evidence that medical supervision and treatment result in improved patient outcomes, but the rationale for lifelong pharmacist involvement every month is unclear,” Dr Ackermann writes.

“Currently, there is no evidence of clinical or other benefit from going to the pharmacy on a monthly basis to obtain these medications.”

He writes that such an extended script life would not be suitable for medicines used to treat all long-term conditions – antipsychotics and analgesics being less suitable.

“The main obstacle to this reform is pharmacy,” writes Dr Ackermann.

“Loss of revenue from prescription, administrative and handling fees would be significant. If you went to a chemist today and got 3 months’ supply of a drug, they can charge you three times the drug cost and three times the markup on the drug, plus three times the administration fees and three times the dispensing fees.

“Under the new proposal, they could charge three times the drug cost and markup, but only charge you once for the dispensing fee.

“Pharmacy may well invent any number of reasons why this change should not be implemented, but the PBS was introduced for efficient and effective delivery of medications, not to sustain the business models of pharmacy.

“If two-thirds of medical visits were demonstrated to be unnecessary, there would be a major review and immediate change to clinical practice. Pharmacy should be no different.”

At the time of writing, MJA InSight readers largely agreed with Dr Ackermann’s position.

In a poll below the article, 67% of readers (108 votes) selected “strongly agree,” with another 6% (10 votes) selecting “agree”.

However a sizeable minority – 23% or 37 votes – selected “strongly disagree,” with another 2% (4 votes) selecting “disagree”.

The article also attracted a number of comments, with one respondent saying that “the only reason why this proposal wont suit pharmacists is that they lose dispensing fee income – ignore their shroud waving about waste or hoarding or patients at risk of overdoing or whatever” (sic).

Another said such a move would be “long overdue” while a third said that “there is simply far too mich (sic) political influence of pharmacy on government, for all the wrong reasons”.

However another commenter said that Dr Ackermann was “blurring things” and that the articles he cited showed such costs were “primarily the costs of going to the GP monthly for a new prescription prior to dispensing (e.g. as per NHS model), not the dispensing of medication when a number of repeats have been prescribed”.

Other commenters pointed out the existence of Regulation 24 (49), with one stating that the uptake of this option is “very low”.

Dr Ackermann responded to this comment, noting that several conditions surround this regulation.

Victorian branch president of the Pharmacy Guild Anthony Tassone expressed disappointment in the MJA piece.

“Unfortunately, Dr. Ackermann is at it again cherry picking the ‘facts’ of his own convenience,” he told the AJP.

“For instance, in one of the journal articles he cited as ‘evidence’ to support his argument, the study found that not only did longer length prescriptions were associated with more medication waste per prescription but that the ‘prescriber time costs accounted for the largest component of total unnecessary costs’.  

“Also, expecting patients to see their doctor more frequently when starting a new medicine—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.

“I can’t say I have heard patients complain about the frequency they need to visit a pharmacy, the most accessible and convenient primary health care destination compared to having to pay a consultation fee for a prescription from a doctor,” said Mr Tassone.

“Perhaps what we should be really talking about is 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.”

Dr Ackermann’s MJA InSight piece can be read in full here.

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  1. Gavin Mingay

    That is a great idea Dr Ackermann, let’s give out boxes of 200 Oxycontin 80mg or 500 Endone tablets. That would save the government a great deal on dispensing fees, plus having to see the GP every few days for a new script, plus it would save the environment – think of all that wasted plastic and foil…

    • Chris Sharp

      He literally says in the article that analgesics would be an inappropriate choice.

      (EDIT: Please don’t make me have to defend Dr Ackermann, of all people)

      Anyway, it reminds me of New Zealand, where three month supply is available for many things.

      • Gavin Mingay

        But why stop there? How many elderly people do we have on regular benzos or opioids for whom it is an inconvenience to come to the pharmacy every ten days or so? They have to see their GP every week or so, costing thousands every year for doctor visits… (the drugs might not be appropriate, but are being used chronically..)

  2. Andrew

    Evan has a point.

    IME a significant proportion of patients don’t (or wouldn’t) benefit from the monthly pharmacy visit – it’s an inconvenience more than anything.

    • Andrew Duffus

      Sorry Anthony, I hear them complaining every day, in a inner city setting about how monthly visits are so terribly inconvenient.

  3. matthew

    Im a pharmacist myself but i must say Dr Ackermann does make a valid point. aside all of the vitriol currently going on between our profession and the doctors profession which is a completely different discussion altogether , if a patient is assessed by a doctor to be competent and regular enough with their medications, then i see no issue with increased supply.

    • Jarrod McMaugh

      Out of interest, when was the last time you had a discussion with a person about their medication and they made the comment that they have stopped a medicines, but didn’t want to tell their doctor about it?

      There are many issues with Dr Ackermann’s article, but the biggest one is that it completley discounts the clinical role of pharmacists.

      Every prescription involves clinical input from a pharmacist (when delivered at best practice). Side effects, misunderstandings, non-compliance, and especially technique with devices such as inhalers, subcutaneous injections, BGMs, are often detected at this point.

      In fact, the government has recognised this when funding 6CPA clinical interventions.

      Perhaps what should occur is pharmacists become prescribers, and then GPs can be removed (since they are shown to be even less value for money by the studies Evan discusses) and pharmacists can work with specialists, cutting out the inefficient “middle” profession

      • matthew

        Absolutely this happens all the time where patients stop medications and don’t inform their doctor, and we have a big role to play for them . Where Dr Ackermans argument is valid is your compliant patients who take their crestors and coversyls every single day without fail, hence the doctors will have to have an appropriate screening program which would take time and maybe money, something i dont believe they would do .

        Dr ackermans suggestions would only work but it would take professional investment from doctors , and i dont think they will do that, hence us pharmacists will continue doing what we do which is filter out every single patient on a monthly basis .

        Pharmacists prescribing certain medications is long overdue!

      • B Lee

        I am very glad I was not the only one thinking GPs as “inefficient middle profession”. To be honest, I do not know why General Practice is even classified as “specialist”.
        I am not really proud of my profession as a pharmacist due to the path this profession is taking and I value GPs as doctors who received many more years of education and training than us but I have to say, GPs are not that superior compared to the pharmacists in terms of patient health outcomes. Talking to GPs at work and even the treatment I received from GPs was shockingly below the expectation than what you would normally expect from what AMA claims “highly trained professionals”. I now trust more specialists than GPs and I really do not say directly but I hope my patients do not get the same treatment I received from some GPs of below standards because truly, it is concerning and worrying. So let’s not be arrogant please GPs… Let’s focus the most important thing, patient health.

  4. PharmOwner

    If Dr Ackermann is so concerned about “Exorbitant costs of routine medication repeats” a good place to start would be with the minority of his colleagues who refuse to prescribe repeats for patients who are stable with their medications. Some of my patients complain about having to see their GP every month when they’ve been on the same medication for years. The reason for refusing to prescribe repeats appears to be greed. Those who live in glass houses…

  5. We had already done this some time ago. We had PBS quantity increases on many medications – one Ventolin to two, increases in Paracetamol PBS quantities for example among quite a few others. It was done to the extent that it was done where it was safe and better to do so and was done and to save the patients some costs (and of course the Government). So we have participated in such measures and one need look no further than S100 and the large quantities supplied in those instances. So Evan your suggestion itself belongs to another period, one where it has already been implemented with the support of our profession.
    We must NOT discount our worth in being accessible to the regular prescribed medication users who from time to time may seek further counselling or advice or through medication profile changes (such as new drug interactions from introduced medicines) may require further counselling, intervention and or advice. Often the patient on say, antidepressants, may need support or may want to ask about over the counter medicines or often finds that they are not required to see their GP for months and you (the Pharmacists) are it when it comes to accessible professional advice on their medication. Repeat prescriptions of one months duration on supply are a safety measure and ensure that the patient returns to the health care environment from which the medication is dispensed so that they have access to professional advice should that be necessary. The prescribers should be delighted that this occurs because we as the “Gate Keepers” of Medicine supply in the Health system can provide one more level of safety and assurance of compliance on what the precriber has ordered on their precsription. One less medico-legal threat because mishaps are prevented – by us!

  6. Michael Post

    Many pharmacies supply more than 1 month at a time frequently due to consumer demand and occasionally for pure financial benefit.

    We all have patients constantly on holiday remaining within this country seeking multiple supplies despite access to pharmacy.

    If a drug is inexpensive, not an addiction or diversion risk for stable maintenance therapy I have no problem with multi month prescription and supply.

    Most customers miss or cease meds in my experience because monthly visits to a pharmacy are just too hard for them for some reason and several days of missed dose monthly as a result are frequent. Multi month doesn’t solve the problem but reduces it.

  7. William

    I think that the original restriction to taking all repeats at once and was introduced by the Government (for PBS/Repat items) to stop hoarding and waste of medicines. This was rampant in the 1960s. It was to save the government money and waste so the Government took action, nothing to do with pharmacists who had to obey the PBS rule.
    There was incredible waste of money occurring so the concept was good.
    Over the years it morphed and has progressed to this ridiculous state where a script cannot be refilled until nearly 3 weeks have elapsed, if it is then it does not count towards the patient safety net. Even if Reg 24 is used it disqualifies the patient from the safety net sticker which is a shame for the elderly.
    I am sure Dr Ackermann is trying to deflect attention of the exorbitant recommended AMA fees so many GPs charge. That is a typical protection tactic for trade associations. In addition they have the nurses pushing for more responsibility, not to forget their beef with APHRA naming individuals investigated.

  8. Toby

    The only anachronism that needs to go, is Dr Ackermann’s attitude to pharmacy.

    • Michael Khoo

      Sadly, yes. Extreme and provocative statements from people in authority make the path to compromise and resolution more difficult.

      Although I am a great believer in the expanded clinical role of community pharmacy I have, for example, as many doubts about pharmacist prescribing as I have about Medical practitioners dispensing. When I try to discuss these and other concerns in a forum like this one, or even in over the dinner table, I really notice how polarized and dogmatic people on all sides have become.

      I am afraid Dr Ackermann’s extreme and inflammatory utterances are not helping “the adults in the room” find a constructive and progressive solution to the challenges of delivering a unified and comprehensive health care solution for the Australian community. I’m sure we all want that…don’t we?

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