Who should pay?


Female Pharmacist and Female Customer Consult Room Blood Pressure_4

When you take a patient’s blood pressure, provide smoking cessation advice, or spend time answering questions about medication use, where should the money come from?

It’s the question on everybody’s lips.

Community pharmacists are increasingly providing valuable health services, but only some of these are funded through the 6CPA.

Currently many pharmacists are providing these services free of charge, while others have attempted to implement a user-pays system – however these haven’t always gone down well.

Some consumers become outraged at the thought of spending money for something they have always received for free.

One AJP reader told us that three months ago he was “physically threatened for asking for a gold coin to take a person’s blood pressure”.

There is also a perception that pharmacists’ time or skills aren’t very valuable (just look at Thinkergirls’ recent critique, where KiisFM co-host Kristie Mercer suggested pharmacists take way too long to just slap stickers on boxes).

Restrictions on 6CPA pharmacy programs also mean not all services or patients are covered.

For example, while pharmacies are funded to provide MedsChecks, eligibility is restricted. To be eligible, a patient must be taking five or more prescription medicines; or have had a recent significant medical event/diagnosis; or be taking a medication associated with a high risk of adverse events.

Another bugbear for accredited pharmacists is the current cap on Home Medicines Reviews, with approved service providers only able to conduct and claim up to a total of 20 HMR services per calendar month.

Is it time for MBS-style funding for pharmacist professional services?

This suggestion has gained support among many pharmacists as well as other health professionals.

“Would love to see some MBS-style funding in the pharmacy … this will decrease the reliance on co-selling shampoo and vitamins, while showing the government and customers that pharmacist advice has value,” says AJP reader fiquet.

“Couldn’t agree more!” says pharmacist Ron Batagol.

“MBS type of remuneration for professional services for pharmacists… Many of us have been advocating this for years, so far to no avail!”

But what would such a system look like?

One option could be to apply for two item numbers: one for a long consultation and another for a short consultation, suggests pharmacist Manya Angley in her AJP piece ‘MBS funding for pharmacists’ professional services: is it time?’

“The long consultation would be along the lines of a HMR or RMMR; a comprehensive medicines review, in a location of the patient’s choice with a comprehensive written report forwarded to the GP.

“A short consultation could focus on a specific medication-related issue including:

  • medication reconciliation for patients going to hospital for an elective admission and/or on discharge;
  • patients suspected of non-adherence;
  • patients identified as likely needing a dosage administration aid (DAA);
  • follow up after a long consult (HMR or RMMR equivalent);
  • device use;
  • falls risk analysis;
  • suspected adverse effect;
  • adverse effect monitoring for toxic medicines; and
  • smoking cessation.”

PSA national president Shane Jackson says professional services payments need to be implemented – but whether that money comes out of the MBS or future CPAs remains to be seen.

“Pharmacists should be able to sit down with a patient, identify what their needs are with regards to their medication management, work out how to address these issues, provide advice to the patient and their GP if necessary regarding those issues and be able to claim for that consultation,” Dr Jackson tells AJP.

“Whether that is an MBS payment or a pharmacist payment that is funded out of future pharmacy agreements remains to be seen. Certainly, we believe that pharmacists should be included on the list of allied health professionals that can deliver consultations (on referral from a GP) as part of team care arrangements.

“We should have pharmacists delivering consultations that are focused on improving medication management and then the pharmacist should be able to submit a claim for payment for these consultations.

“This would transform the landscape of pharmacist delivered services across the country.”

Dr Jackson says pharmacists should be considered equally alongside other healthcare practitioners when it comes to the MBS.

People with chronic health conditions and a doctor’s referral can visit the following allied health practitioners and receive rebates under the MBS (with a limit imposed on how many services can be used for each per year):

  • Aboriginal Health Workers or Aboriginal and Torres Strait Islander Health practitioners
  • Audiologists
  • Chiropractors
  • Diabetes educators
  • Dietitians
  • Exercise physiologists
  • Mental health workers
  • Occupational therapists
  • Osteopaths
  • Physiotherapists
  • Podiatrists
  • Psychologists
  • Speech pathologists

“There is no reason that pharmacists should be excluded from the MBS from the perspective of participating in team care arrangements for patients with chronic disease. We should be there, because medication management is such an issue in this country,” argues Dr Jackson.

“Equally, pharmacists should be able to initiate a spectrum of consultation types based on the needs of the patient to be able to help with medication-related issues. General practice has this model with their Level A, B, C, D structure, which we should consider in developing this model of practice for pharmacists in Australia.”

Recent figures reveal that the amount spent by Medicare on GP visits in 2015-16 equated to an average of $302 per person.

This ranged from $226 per person in the ACT PHN area to $359 per person in the Western Sydney PHN area.

Nationally, 85.1% of GP attendances were bulk-billed in 2015-16.

Dr Jackson is hopeful that changes can be made for funding of pharmacist services if those in the profession make their voices heard.

“I believe there is always opportunity for improving how our health system is structured and funded, we just need to have the collective desire to grasp the opportunity for improving practice and improving outcomes for patients,” he says.

Agreement across the board

The Pharmacy Guild of Australia is on the same page as the PSA.

“Certainly we support the notion that health professionals delivering the same services should be paid the same way – as has been recommended in the Interim Report of the King Review,” says a spokesperson for the Guild.

“The key is to acquire appropriate remuneration, whether it might come from a Pharmacy Agreement or the MBS.”

Surprisingly, the Australian Medical Association (AMA) is supportive of an MBS-style system for pharmacists, despite having been at odds with pharmacy groups so many times in recent months.

In its submission on the King Review Interim Report, the AMA says there are there are benefits to future CPAs being limited to remuneration for the dispensing of PBS medicines and associated regulation, with pharmacy programs funded separately.

“This would allow pharmacy programs, such as medication adherence and management services currently funded under the agreement, to be funded in ways that are more consistent with how other primary care health services are funded,” it says.

“Given these programs are about providing health services, rather than medicines dispensing per se, it makes sense for them to be assessed, monitored, evaluated and audited in a similar way to medical services under the MBS.”

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22 Comments

  1. Andrew
    07/09/2017

    There’s plenty of money in the CPAs for pharmacy services – just stop wasting it on non-productive BS that’s little more than clinical theatre.

    If it’s evidence based and can demonstrate improved QoL in the “customer”, fund it (DAA, HMR, medication counselling). If not (Medschecks, POCT) don’t. Easy.

    • David
      07/09/2017

      Well done Andrew. I agree

    • Big Pharma
      07/09/2017

      Although, management of CPA funds needs to be independent of the PGA. Otherwise the MBS IS needed so services that are evidence based can be added, audited and removed if necessary.

      Otherwise non evidence based services expand (medschecks). Funding is funnelled through channels of self interest rather than those of most benefit.

      Interestingly the article indicates medschecks are overly restrictive. I would argue they are not strict enough. Vague criteria such as “new diagnosis”, “taking medication with a risk of adverse effects” can pretty much be sculpted to any scenario….and if the new Rx presented is metformin then you get paid a bonus. I guarantee under these criteria high-risk complex patients are ignored/avoided as they are time consuming and there is a focus on throughput. Under the MBS this is monitored and audited.

      • Andrew
        07/09/2017

        Pretty much agree. PGA administering the funds is an egregious conflict of interest. There’s zero accountability or transparency (I asked, was basically told to FO), and from what I can gather no accountability for outcomes. Administer funds by an independent body, bring other parties to the negotiating table, and lock in KPIs linked to community health for the CPA allocations.

        • David
          07/09/2017

          Here’s an idea. Lets see what the highest cause of preventable hospitalisations are, and focus on those for programs. Primary health is designed to prevent hospitalisation isn’t it. Keep it simple

    • Anthony Tassone
      07/09/2017

      Andrew

      As has been discussed previously on online forums, there will be a cost effectiveness assessment of medication management programs under the 6CPA.

      The cost effectiveness assessment is important and required to gain future funding, as set out in Clause 6.1.3 of the Sixth Community Pharmacy agreement;

      “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.”

      Until these cost effectiveness assessments have been completed, it is premature to state what services should be excluded from funding beyond the 6CPA.

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

      • Andrew
        07/09/2017

        Yes, I understand that part.

        Can you comment on the cost effectiveness decision that saw funds shifted from HMRs to the (as I understand still at trial stage) MedCheks? I asked for some clarity on this from the Guild and was basically told to mind my own business – do you support this secretive method of apportioning funds, or are you supportive of more transparency?

        • United we stand
          07/09/2017

          That moment when even the president of PGA tells you to FO 😂😂😂😂

        • Willy the chemist
          07/09/2017

          Hi Andrew, I keep reading about evidenced based HMRs and as far as I’m aware there’s the VALMER study that basically states that HMRs cost benefits only in the upper quartile. That to me is not evidence of the HMR program being evidenced based.
          Can you please say this objectively or otherwise can someone please please provide me with a study that support their claims? I’ve asked this a number of times and unless pharmacists et al would like to continue to sweep into each other’s faces, I will like more evidence of your claims of evidenced base HMRs.
          Thanking you in advance.

          • Andrew
            08/09/2017

            Fair point. HMRs have the strongest evidence for patient and community health and has the best RoI of all the professional services. Comparing the evidence around the competing professional services there’s no question that HMRs are the most efficacious.
            With respect to the benefits only in the upper quartile – IIRC that’s due to the period of the study being too short. I don’t have time to re-read it now but I’ll try to revisit it over hte weekend and get back to you.

          • David
            10/09/2017

            I know back in the old days an accredited pharmacist who would go into a doctors surgery with an assistant and smash out 8 hmrs in 1 day. I read the reports, and they were tripe. Not thorough at all. The doctor and the pharmacist were rorting he system. We need limits in place so this doesn’t happen again. I do Hmrs, and know the time involved to do them properly. About 1 to 1.5 hours for interview and about 2 hours for the report uninterupted.

          • Big Pharma
            11/09/2017

            It is a home medicine review….what you described is medicare fraud. Setting limits (within reason) is not the issue. An experienced accredited pharmacist, working full time could do 15-20 high quality HMRs/week comfortably. The program requires an auditable accountable process to extinguish fraudulent behaviour (MBS). Currently, under heavy restrictions, there remains no incentive other than personal ethics to produce quality reports. From what I’ve see quality has in fact diminished since the caps as those with most experience and those most qualified have moved on. Direct, unrestricted referrals are essential like every other area of healthcare! However the person/pharmacy in whom the referral is directed must do the review (no corporate set ups)

          • David Lund
            11/09/2017

            Sure, you could work full time and do 15 to 20 a month. If you don’t want to have any free time for yourself. What a joke!

          • Big Pharma
            11/09/2017

            I’m Suggesting a reasonable cap to allow full time work. 15-20 hmrs/week. Although as I said the cap is not the issue, it’s the auditability.

            20/month cap promotes fast tracked KPI box ticking hmrs. Poor clinicians get work purely from overflow from quality providers. Clearly this is not the best way to maximise the program.

        • Anthony Tassone
          08/09/2017

          Andrew

          When are you referring to “funds shifted”?

          The recent landmark compact as part of the 2017 Federal budget between the Pharmacy Guild and the Federal government that saw the opening of access of the $600 million previously held in contingency reserve for pharmacy Trial Programs that were progressing to a further roll out and expansion of delivery increased a funding allocation to MedsCheck to allow 20 services per month. This has not “shifted funds” away from HMRs as HMRs have continued to be funded at the same level allowing up to 20 services per month for a service provider.

          Whenever there is a fixed bucket of funds and the need to keep within finite budgets there is a challenge for both the Australian government and the Guild in allocation to a range of medication management programs and services for consumer benefit.

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

          • Andrew
            08/09/2017

            You know what I mean, Anthony. So does everyone else. I think your answer is evasive and disingenuous.

          • Anthony Tassone
            08/09/2017

            Andrew

            Honestly if I knew exactly what you meant I wouldn’t have asked. Those who know me would understand that. I answered the question that way as I’ve been asked that question a number of times recently.

            If you’re referring to the funding allocation towards HMRs in the 5CPA compared to the previous agreement I return to my earlier point about the challenges of funding a range of medication management services from a finite budget especially with introduction of new services.

            During the 5CPA when there was first a detected overspend of the HMR program, it was actually topped up by approximately 30% from reallocation of other programs including clinical interventions. This ensured there was no interruption in service delivery of the program.

            Going forward demonstrating cost effectiveness and having medication management programs funded via an MBS style approach would be preferred than managing from finite capped budgets.

            In terms of your claim of my post being “evasive” if I wanted to be truly evasive I would simply not reply or post at all but make best efforts to try and provide responses and clarification when asked.

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

  2. David
    07/09/2017

    Why can’t we access private health fund money?? People are paying mortgages each month to have it, surely pharmacy services are worthy of some of the pie. Especially for services that prevent hospitalisations

    • Andrew
      07/09/2017

      Maybe we pharmacists could have a lobby group to advocate on these types of things on our behalf.

      • David
        07/09/2017

        That’s the guild’s job. I faulk out enough each year for them to do their job while I’m busy doing mine. I spend some of my free time on here so I can get my message out there so i can keep doing the iob I wanted to do till i retire

        • Andrew
          07/09/2017

          I was being facetious.

          Our advocacy group ain’t great at advocating.

          • David
            07/09/2017

            You are right. Time to see some results!!

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