The big debate: HMR versus MedsCheck

Recent pharmacy program changes have been criticised over perceived lack of funding for HMRs – but is there potential for them to be funded through the MBS in the future?

The provision and allocation of $600 million for community pharmacy programs was announced last week by the Department of Health and the Pharmacy Guild of Australia.

Of this amount, $90 million has been allocated towards expanding the MedsCheck and Diabetes MedsCheck program.

However while the number of MedsChecks and Diabetes MedsChecks that can be conducted and claimed by community pharmacies is set to double, HMRs have been left predominantly untouched – for the meantime.

“The HMR program will continue unchanged from 1 July 2017,” stated the Pharmacy Guild in its announcement, with a review of the program to be undertaken.

Potential changes to HMRs include two new in-pharmacy follow-up services and increased access for Aboriginal and Torres Strait Islander patients, anticipated to commence in early 2018.

In order to implement these follow-up services, which include the implementation of a Medication Management Plan (MMP) by the community pharmacy, and post-review follow-up by the patient’s community pharmacy after approximately six months, $60 million has been allocated.

A “disappointing” outcome

The decision has left accredited pharmacists fuming that funding has been extended to MedChecks but not HMRs, and the cap has not been removed from HMRs despite strong evidence for their benefit.

“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 belief,” says Karalyn Huxhagen, a consultant pharmacist from Queensland.

“Under [Sussan Ley] 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,” says Ms Huxhagen on the AJP website.

Clinical consultant pharmacist John Wilks is also unhappy with the situation.

“HMRs are a proven world-class primary prevention strategy that my colleagues overseas look upon with envy and awe,” says Mr Wilks.

“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.

“I have been now accredited for 20 years and have a strong relationship with more than 20 doctors, hence my continual carry-over each month of HMRs. Why does an organisation that I do not belong to decide my professional future?” he asks.

SHPA Chief Executive Kristin Michaels says leaving the HMR Program unchanged is “disappointing” and will limit patient access to an under-resourced service.

“HMRs performed by independent pharmacists, including follow-up in the home where patients are most comfortable, are a proven and effective way to expanded medication management services for Australians who need additional assistance,” says Ms Michaels.

“HMRs, including hospital-initiated referral pathways for high-risk patients, have the strongest evidence base of all 6CPA programs—including many which have just been expanded – so it is disappointing to see them overlooked,” she says.

Consultant clinical pharmacist Debbie Rigby agrees that the most concerning thing about the allocation of the $600 million in funding is the continued caps on HMRs, despite their having “high level evidence of clinical impact, patient satisfaction and cost-effectiveness.”

She says that while MedsChecks have their place in pharmacy, they are not a replacement for or equivalent of HMRs.

“I think MedsChecks are a good service, if delivered according to the program rules. The benefit of knowing the patient through the community pharmacy is obvious,” says Ms Rigby.

However she says that, in context of a patient taking a medication at high risk of adverse events, at best MedsChecks would identify a patient likely to benefit from an HMR.

Assessing a patient taking a medication at high risk of adverse events generally requires additional information including diagnosis and lab test results, which are not generally available in the pharmacy.

“MedChecks aim to help patients learn more about their medicines, and educate patients how to use and store their medicines. It is neither comprehensive nor collaborative with GPs.”

Ms Rigby has positive things to be say about the potential changes that include in-pharmacy follow-up services, but adds that consultant pharmacists should be utilised throughout the process.

“I fully support changes to the program rules for HMRs to enable greater access to ATSI populations. The potential changes to the HMR program rules and funding to allow two new in-pharmacy follow-up services is a good idea.

“If the accredited pharmacist does not also work in the pharmacy, then they could be contracted to conduct a session in the pharmacy for that follow-up service,” Ms Rigby suggests.

“I think it could be a good model as it doesn’t fragment the outcomes of the HMR, continues the contact and relationship with the GP, and fosters better collaboration and support to the community pharmacy.”

Potential for positive change?

Jarrod McMaugh, Managing Partner at Capital Chemist Coburg North in Victoria, thinks there are positive changes ahead for consultant pharmacists.

He says the growth of MedsChecks and Diabetes MedsChecks is “one that is causing a lot of consternation amongst provides of HMR services who see a MedsCheck as ‘HMR-lite’ when it clearly isn’t”.

“There has been much criticism of the fact that the announcement did not include an increase in the caps on HMR… yet it seems to me that the review of HMR is still underway,” says Mr McMaugh.

“This should be welcomed by all stakeholders, since it would seem that the criteria for eligibility will be expanded (although this is not guaranteed).

“I think the fact that there is an ongoing review is a sign that there will in fact be a significant increase/expansion of the service,” he suggests.

Mr McMaugh says he is very happy that as part of the 6CPA agreement, there will now be a mechanism for follow-up of the recommendations in an HMR, and that this will be done within the patient’s preferred pharmacy.

“This ensures that these recommendations are communicated to the pharmacists who are actually going to have the most contact with the patient and can therefore implement the changes,” he says.

Victorian Guild President Anthony Tassone explains that HMRs and MedsChecks are currently undergoing cost-effectiveness assessments.

“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,” says Mr Tassone.

“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.”

Ms Rigby isn’t convinced.

“All existing programs are undergoing cost-effectiveness assessment. Changes have been announced to MedsChecks starting 1 July 2017 i.e. doubling caps and additional eligibility criteria without this cost-effectiveness assessment; and yet HMRs (for which there is substantial evidence of benefit and cost-effectiveness) has no changes. Seems a double-standard,” she tells AJP.

King Review Interim Report

The King Review Interim Report, released last week, has called for an expanded HMR program, appropriate remuneration for services and a lifting of the HMR cap.

“A Home Medicines Review (HMR) is clearly a place-based service and needs to be provided in the home or other appropriate location,” say the panel members, led by Chair Professor Stephen King.

“The [HMR] program was a significant focus of feedback received by the Panel during consultations,” says the panel.

“There was much anecdotal evidence provided of the benefits of the program and the problems caused by the introduction of the cap. 

“The Australian Government should investigate options to optimise the current HMR program, with the aim of reducing medicine-related problems and avoidable hospital admissions,” the King Review panel recommends in its interim report.

“In particular, an increase in the current cap on services provided each month should be considered, combined with more targeted eligibility criteria to ensure the program reaches patients with the greatest need. Further, the government should investigate the potential benefits of opening the referral pathways to allow hospital staff to refer patients upon discharge,” it says.

“The consultant pharmacy model supports the view of medicine review as an advanced area of pharmacy practice. Further, the continuation of the direct referral system provides better choice for consumers and GPs, who can refer to those consultant pharmacists who they believe provide a high-quality service.”

The SHPA has welcomed the panel’s support of hospital-initiated HMR referral pathways for high-risk patients, which the organisation has advocated for over the last decade, as well as its confirmation of SHPA’s view toward an ongoing and appropriate level of accreditation and training for pharmacists to conduct reviews.

“Support to lift the cap of 20 HMRs per pharmacist per month and introduce more targeted eligibility criteria are also positive moves,” says Ms Michaels.

See here for more information on HMRs under the 6CPA

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  1. Amandarose

    One can’t help but wonder if funds are so tight why follow ups in pharmacy- Essentially getting paid to do their job is the best allocation of funds. I am will to support such measures if the cap is lifted and they are indicated as necessary by either the patient, doctor or pharmacist and not abused as a way to generate some easy cash. I cam think of cases it would worthwhile and others where it is not indicated. The Guild trying to manipulate things so the get a slice of every pie worries me

    • Andaroo

      I think, “Essentially getting paid to do their job is the best allocation of funds”, would have been a more accurate statement if it had read, “Essentially getting paid to do the job they do now for free is the best allocation of funds”.

  2. Jarrod McMaugh

    I like the idea of an accredited pharmacist providing the follow up review, but I disagree that it would be fragmenting care to have the patients’ preferred pharmacist provide this review. Funding for a collaborative meeting would be great – this would ensure that the pharmacist whom the patient sees more often than any other health professional is included in process as they should be. I note that the term “fragmentation of care” is something often used by doctor’s groups to criticise services provided by pharmacists, & it’s disappointing to see this red herring used in this conversation, since it is a synonym for siloing of services.

    • Big Pharma

      Does the community pharmacy contact the GP to put together the MMP? It’s not up to the accredited pharmacist to put together a MMP for the community pharmacy based on their follow-up discussion with the GP. Sending a copy of the HMR report to the pharmacy for their records is only half the picture (pending GP response). So I ask the question yet again, what is being followed up? How does the community pharmacy know what changes have been implemented and which are deemed inappropriate?

      • Jarrod McMaugh

        We do actually implement and influence the MMP. My job on a regular basis includes comparing HMR report from the accredited pharmacist and recommendations from the GP based on this.

        I talk to the GP about their thoughts on the HMR report. It is rare that it doesn’t engender some discussion, and occasionally debate. On some.occsdions I have pushed the GP to implement a recommendation from the accredited pharmacist, and in some rarer cases I have pushed to disregard one.

        The point is to ensure best outcome for the patient. I need to know what the HMR recommends. I need to know what the GP implements. I need to know what the patient wants. I help the patient get the best of this situation.

  3. Big Pharma

    HMRs vs Medschecks….there is no doubt one is an evidence based collaborative service with a proven ability to reduce costs via decreased hospital admissions and reduced PBS expenditure (also requires a referral). The other is a cash top up to lessen the impact of price disclosure.

    It has taken the common sense of an independent Economist and panel to draw attention to the obvious benefits of HMRs. Disappointing this can’t be achieved in house within the profession. How medscheck expansion and HMR community pharmacy “follow ups” can be pursued, expanded and funded without cost-effective assessment whilst a premium collaborative service stands still is an absolute joke.

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