Insure for pharmacist services, high-cost drugs: Guild

graph made of medicines

Pharmacist services should be included in subsidised private health insurance cover, the Pharmacy Guild argues

In its submission to the Senate Community Affairs Reference Committee inquiry into the value and affordability of private health insurance and out of pocket medical costs, the Pharmacy Guild says that medication management following hospitalisation, and pharmacy services which help avoid hospitalisation, should be subsidised coverage options.

Government support for private health insurance should focus principally on enabling patients to insure themselves to help cover the costs of hospital and related costs beyond that provided in the public system, it says, as well as “larger unforeseeable medical costs that are not subsidised through the publicly funded health system, such as providing specialised non-PBS medicines for chronic and life-threatening conditions”.

Subsidies for ancillaries should be restricted to those for which there is good evidence of cost-effectiveness, the Guild says.

“Post-discharge medicine reconciliation is an obvious example as are diabetes care and point-of-care testing for at-risk patients with chronic health conditions.

“Preventative and wellness programs focused in areas such as smoking and obesity, which are proven to reduce the onset of preventable chronic conditions that put patients at high risk of hospitalisation should also be included.

“Some current private health insurance ancillary services have little or no link to hospitalisation and arguably should not be subsidised by the Government.”

Rule 12 of the Private Health Insurance Rules is unnecessarily restrictive, says the Guild.

This rule covers chronic disease management programs, and lists a group of allied health service providers, from Aboriginal health workers, audiologists and chiropractors to dieticians, osteopaths and speech pathologists, whose services are eligible for coverage.

This rule should be altered to “allow private health insurers to access health professionals such as pharmacists for the treatment of patients with chronic health conditions.

“This is particularly important given many of these patients have highly complex medicine regimens, and medication non-compliance is one of the principal causes of unnecessary hospitalisation,” the Guild argues.

Patients should also be able to insure themselves to access non-PBS subsidised, high-cost medicines for chronic or life-threatening conditions, the Guild submits.

“With the onset of complex, specialised and personalised medicines, the need to access these expensive treatments in the private market is increasing.

“Like hospital costs, they are treatments that many patients cannot reasonably be expected to access from their existing financial resources and should be insurable.”

The Guild called for greater transparency and reduced complexity overall, saying patients need health insurance products to be “clear, understandable and to provide maximum certainty and peace-of-mind in relation to both their level of cover and their out-of-pocket costs,” and singled out private scripts in relation to the issue.

“Health insurers should provide greater transparency and certainty for patients regarding the medicines they cover and the level of cover.

“Patients should be able to insure themselves at levels that minimise the cost of these medicines and should have the flexibility to utilise their wider general treatment pool (and possibly their hospital pool in defined circumstances) to assist in the cost of the provision of these medicines.”

The Guild says that while private health insurers should be encouraged to proactively manage their patients to reduce unnecessary hospital admissions and readmissions, their role is not to establish an alternative primary health care system.  

“Rather they should concentrate on financially enabling the delivery of services that are linked to their core hospital related purpose, working with existing primary care providers such as doctors, nurses, pharmacists and allied health professionals,” the submission says.

“For example, medication management support immediately post discharge from hospital should be explicitly recognised as a bona fide part of hospital cover.  This would ensure continuum of patient care and reduce medication related readmissions.”

The Guild also questions the validity of measures such as the Lifetime Health Cover which were intended to drive take-up of private health insurance.

“Both Lifetime Health Cover and the Medicare Levy Surcharge effectively are ‘sticks’ to encourage younger and higher income individuals and families to take out private health insurance, with the twin objectives of reducing the burden on the public system and broadening the pool of privately insured policy holders beyond those most likely to require hospitalisation.

“However, it is not clear whether either of these policies is effective in achieving its objectives or whether alternatives such as rewarding non-claiming policy holders and requiring higher income earners without private health insurance to make a financial contribution to their public hospital costs would deliver better health and fiscal outcomes.

“Community rating should be retained to ensure older, sicker patients continue to have affordable access to private health insurance. However the current risk equalisation system penalises health insurers that actively try to help their higher risk patients stay out of hospital.

“A prospective risk-based capitation system would encourage insurers to invest in preventative health and chronic disease and medication management systems, leading to cheaper premiums and better health outcomes.”

Read the full submission here.

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