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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