The purpose of this paper is to describe the current situation for Aboriginal and Torres Strait Islander people obtaining a prescription for medicine under the Pharmaceutical Benefits Scheme and dispensed by a pharmacy – be that in a hospital, the community setting or from an Aboriginal Health Service either government owned and operated or under community control.
Introduction
The past ten years has seen some effort put into improving the compliance rate and health gains by Aboriginal and Torres Strait Islander people from the use of western medicines. Emphasis has been placed on chronic disease conditions which are having a serious impact on longevity of life and forcing a wide gap in life expectancy between Indigenous Australians and non-Indigenous Australians. The average “gap” is shown to be 17 years although by region those living in remote areas of Australia have a lower life expectancy and are thus crucial to “closing the gap” on an Australia wide count.
The past ten years has seen some effort put into improving the compliance rate and health gains by Aboriginal and Torres Strait Islander people from the use of western medicines. Emphasis has been placed on chronic disease conditions which are having a serious impact on longevity of life and forcing a wide gap in life expectancy between Indigenous Australians and non-Indigenous Australians. The average “gap” is shown to be 17 years although by region those living in remote areas of Australia have a lower life expectancy and are thus crucial to “closing the gap” on an Australia wide count.
Background
The respective stakeholders in primary health care each has a concern for the health of Indigenous Australians. The needs of the patient must be paramount over the processes that suit a mainstream population. Too often remote living Indigenous Australians have been forced to accept a mainstream model of service delivery when their needs reflect more that of a Third World country requiring a program designed to specifically meet their needs. This applies to the Section 100 PBS to remote AHS arrangements. In urban areas where possible the needs of the patient can be made to fit the mainstream model and this should be done rather than establishing new processes. The QuMAX and Close the Gap programs have failed to do this effectively.
The respective stakeholders in primary health care each has a concern for the health of Indigenous Australians. The needs of the patient must be paramount over the processes that suit a mainstream population. Too often remote living Indigenous Australians have been forced to accept a mainstream model of service delivery when their needs reflect more that of a Third World country requiring a program designed to specifically meet their needs. This applies to the Section 100 PBS to remote AHS arrangements. In urban areas where possible the needs of the patient can be made to fit the mainstream model and this should be done rather than establishing new processes. The QuMAX and Close the Gap programs have failed to do this effectively.
The Federal Government, as the funder, has tried to meet the requests emanating from the prime peak bodies, the Pharmacy Guild and NACCHO. In addition the following have had some part in the lobbying process:
- · The Pharmaceutical Society of Australia
- · The Australian Medical Association
- · Australian Divisions of General Practice
- · Royal Australasian College of Physicians
- · Royal Australian College of GPs
- · Rural Doctors Association
- · National Rural Health Alliance
- · Australian Pharmacy Council
- · The Society of Hospital Pharmacists of Australia
The following programs have been put in place over the past ten years:
- · Special PBS listing of medicines specifically for Indigenous Australians
- · Section 100 arrangements for supply to remote living Indigenous Australians
- · Special allowance for pharmacists supplying remote health services under s100 to implement quality use of medicine measures
- · National Prescribing Service program for “outreach pharmacists” to remote Aboriginal health services (OPRAH)
- · QuMAX program for cost of DAAs to Indigenous patients attending eligible community controlled health services.
- · Close the Gap co-payment relief for Indigenous people attending eligible general practice centres and registered for chronic disease management.
The above programs have solved some problems but in doing so have created problems of their own. There needs to be a “global” look at the whole scene to evaluate where this has occurred and what can be learnt from the past ten years involving operators at the coalface.
In evaluating the cost benefits of these programs it is important to keep in mind the four basic principles of the National Medicines Policy which should be the underlying guide to development of quality pharmaceutical care. These are:
1. Timely access to the medicines that Australians need at a cost individuals and the community can afford – this has been assured across the Nation
2. Medicines meeting appropriate standards of quality, safety and efficacy – including the correct recording and labelling of prescribed medicines in accordance wit the law – this has been assured across the Nation.
3. Quality use of medicines with information to allow the patient to understand the medicines they are getting including effects, side effects, interactions and expectations of outcome. This is available to ALL Australians through a local retail pharmacy – but not remote living Aboriginal people.
4. Maintaining a responsible and viable medicines industry including sustainable research, manufacturing and supply chain to the patient. The s100 to remote arrangements offer a sizeable income to retail pharmacies thus ensuring their viability. The urban programs ensure the “bill” is paid at the local pharmacy by health services and their patients.
Situation analysis
The following comments are now made on each of the above:
The following comments are now made on each of the above:
1. Special PBS listing of medicines specifically for Indigenous Australians
The list is essentially medicines which can be bought over the counter at a pharmacy. The cost of such an item when added to the PBS list and supplied in accordance with a legal PBS order immediately increases the cost to taxpayer by the dispensing fee, safety net recording fee and in the instance of urban dwellers the “additional extra charge”. This result means either the PBS or the consumer is paying more because of PBS listing unless the consumer has a Health Care Card.
The list is essentially medicines which can be bought over the counter at a pharmacy. The cost of such an item when added to the PBS list and supplied in accordance with a legal PBS order immediately increases the cost to taxpayer by the dispensing fee, safety net recording fee and in the instance of urban dwellers the “additional extra charge”. This result means either the PBS or the consumer is paying more because of PBS listing unless the consumer has a Health Care Card.
2. Section 100 arrangements for supply to remote living Indigenous AustraliansThis has increased the availability of the full range of PBS general list of medicines to remote Aboriginal health service. However in devising the reimbursement formula to supplying pharmacies no consideration has been given to meeting the cost of dispensing at the AHS as the PBS does for every other Australian attending an Approved Pharmacy. The result has been poor quality in the standard of pharmaceutical care and no apparent indication of which party is responsible for improvements. The State/Territory governments are responsible for ensuring the legal requirements for supply are being met whilst the Commonwealth should be responsible for ensuring the remuneration is adequate to meet the principles of the National Medicines Policy.
3. Special allowance for pharmacists supplying remote health services under s100 to implement quality use of medicine measures
This allowance has provision for two visits a year by a pharmacist to an Aboriginal Health Service to which the pharmacy is supplying medicines. This is inadequate to meet the needs of the patients attending that centre to understand and comply with the expectations of the medicine. Trust and confidence as a member of the central team is simply not possible with such infrequent visits. Reports of the major mission being to check for out dated stock do not indicate a high level of QUM activity.
This allowance has provision for two visits a year by a pharmacist to an Aboriginal Health Service to which the pharmacy is supplying medicines. This is inadequate to meet the needs of the patients attending that centre to understand and comply with the expectations of the medicine. Trust and confidence as a member of the central team is simply not possible with such infrequent visits. Reports of the major mission being to check for out dated stock do not indicate a high level of QUM activity.
4. National Prescribing Service program for “outreach pharmacists” to remote Aboriginal health services (OPRAH)
This program has the distinct advantage of bringing together pharmacists who are involved in the supply function to remote AHSs. This could provide a forum for a wide ranging discussion on improving quality and the avenues that work but unfortunately due to the policy of the NPS it is an educational session on a topic identified though “focus groups” in mainstream Australia and does not always bear relevance to a vital subject in remote Aboriginal health. If it was more directed to the target audience it could be more relevant.
Participants should be assisted to understand the social determinants for health and where the management of medication use fits in to the overall patient care and prevention of illness process.
This program has the distinct advantage of bringing together pharmacists who are involved in the supply function to remote AHSs. This could provide a forum for a wide ranging discussion on improving quality and the avenues that work but unfortunately due to the policy of the NPS it is an educational session on a topic identified though “focus groups” in mainstream Australia and does not always bear relevance to a vital subject in remote Aboriginal health. If it was more directed to the target audience it could be more relevant.
Participants should be assisted to understand the social determinants for health and where the management of medication use fits in to the overall patient care and prevention of illness process.
5. QuMAX program for co-payment relief and cost of DAAs to Indigenous patients attending eligible community controlled health services.
This program has failed to meet a wide audience of need due to its restriction to the community controlled sector. Funding for this program will cease on 30 June 2011. Even then the bureaucratic processes that have been established have not assisted a rapid uptake of co-payment relief or provision of more DAAs. An examination of the 13 page “Business Rules and Guidelines”[1] is testament to this. The money spent on preparing, implementing and evaluating these could have been well spent in providing a pharmacist to many ACCHOs to do what they wanted in the spirit of community control.
The positive side for NMP purposes is that it assists in paying the bill at the pharmacy providing the services and thus add to its likely sustainability.
The provision of DAAs through this program will cease on 30 June 2011 while this has been seen by pharmacists as a positive aid to adherence. A scheme such as exists for Department of Veterans Affairs beneficiaries is advocated to replace the QuMAX initiative.
This program has failed to meet a wide audience of need due to its restriction to the community controlled sector. Funding for this program will cease on 30 June 2011. Even then the bureaucratic processes that have been established have not assisted a rapid uptake of co-payment relief or provision of more DAAs. An examination of the 13 page “Business Rules and Guidelines”[1] is testament to this. The money spent on preparing, implementing and evaluating these could have been well spent in providing a pharmacist to many ACCHOs to do what they wanted in the spirit of community control.
The positive side for NMP purposes is that it assists in paying the bill at the pharmacy providing the services and thus add to its likely sustainability.
The provision of DAAs through this program will cease on 30 June 2011 while this has been seen by pharmacists as a positive aid to adherence. A scheme such as exists for Department of Veterans Affairs beneficiaries is advocated to replace the QuMAX initiative.
6. Close the Gap co-payment relief for Indigenous people attending eligible general practice centres and registered for chronic disease management support
While the QuMAX program assisted patients of community controlled health services, the Close the Gap program assists patients attending a GP centre or an ACCHO thus replacing the QuMAX scheme. Patients eligible to register must be considered at risk of developing a chronic disease. The notion that cheaper PBS medicine will improve adherence is suspect as at some ACCHOs patients have had “free” medicine for years. This program is simply helping to “pay the bill” at the local pharmacy and not assisting the patient to obtain the quality needed to meet principle three of the National Medicines Policy shown above.
While the QuMAX program assisted patients of community controlled health services, the Close the Gap program assists patients attending a GP centre or an ACCHO thus replacing the QuMAX scheme. Patients eligible to register must be considered at risk of developing a chronic disease. The notion that cheaper PBS medicine will improve adherence is suspect as at some ACCHOs patients have had “free” medicine for years. This program is simply helping to “pay the bill” at the local pharmacy and not assisting the patient to obtain the quality needed to meet principle three of the National Medicines Policy shown above.
To summarise – for the remote living Indigenous Australians there is a second class PBS that provides no help in understanding medicines and their effect on the body but provides a good income to the supplying pharmacies. The cost of dispensing is not being met by the PBS as it does for every other Australian with the Commonwealth saying that this is a State/Territory government responsibility.
For urban living Indigenous Australians there are two systems both of which provide financial advantages to the dispensing pharmacy by ensuring the cost is met by the PBS as opposed to the health service or patient. Where this is advantaging the Aboriginal health service by saving it money on patient co-payments there is no requirement for these savings to be spent on “Quality use of Medicine” improvements.
The complicated bureaucratic process to obtain the benefits is believed by some to be “not worth the effort” while the Indigenous patient has no idea of what the programs are or how best they can access them. Even pharmacists are confused as to what applies to whom.
The complicated bureaucratic process to obtain the benefits is believed by some to be “not worth the effort” while the Indigenous patient has no idea of what the programs are or how best they can access them. Even pharmacists are confused as to what applies to whom.
Recommendations
1. PBS listing – disband the current Indigenous Expert Advisory Panel due to its listings being inconsequential to improving Indigenous health in a cost effective way. Replace it with a panel including people involved in delivering pharmaceutical care services and have a scope beyond just PBS listings and include quality use of medicine measures. The most relevant factor is making product available to Indigenous Australians at the best price through a functioning pharmacy in every Aboriginal Health Service under the supervision of a registered pharmacist.
2. Section 100 Remote – make funds available to AHSs to meet the cost of dispensing on to patients after having received product from a supplying pharmacy. This can be done by initially meeting the cost of dispensing as it applies in mainstream ($6.42 at 1 January 2011). At present 25% of government outlays (estimate $40 million in 2010-11) goes to the supplying pharmacy and nil to the dispensing AHS.
No data is available to analyse drug utilisation as happens with the mainstream PBS. Although this has been called in a review of the program[2] – Medicare Australia is still unable to make publicly available detailed statistics.
No data is available to analyse drug utilisation as happens with the mainstream PBS. Although this has been called in a review of the program[2] – Medicare Australia is still unable to make publicly available detailed statistics.
3. Special allowance under s100 – disband this allowance and put funds into 2) above. The current arrangement provides no value add to the individual patient which is where the focus should be. Pharmacists checking stock for out of date and smoothing administrative arrangements are a waste of professional time.
4. NPS OPRAH program – this should be directed to pharmacists working “at the coalface” and be relevant to the needs of the patients. Past programs such as pain management, stroke prevention, COPD and diabetes are well covered by primary health care specialists in patient education. An evaluation from the AHS level would be of interest.
5. and 6. QuMAX and Close the Gap - should be disbanded and incorporated into the PBS General Scheme with Aboriginal people entitled to whatever concessions Governments of the day believe provides equity and justice. This should NOT be based on where a person attends a doctor as it is now. If all persons identifying as Indigenous and at risk of chronic disease they should be issued with a Health Care Card. If there is a need for an income/asset test then leave that to Centrelink in issuing the card as for every other Australian. There must be a universal Indigenous Pharmaceutical Care program and not one based on the governance structure of a health service. Hospital pharmacies must be included in having access to these measures. At present patients are discharged from hospital with a varying array of quantities and charges. The training provided for Medicare officers and retail pharmacy operators has also failed to meet the need with respect to the detail and cross cultural sensitivities.
Conclusion
As a general principle all benefits should be made to fit a program developed with the Indigenous patient as the beneficiary. The PBS contains various elements that can be utilised to suit the need. There is no reason why NGOs such as the Pharmacy Guild, NACCHO or Divisions of General Practice, should be involved in delivering a program that falls within the scope of PBS capability with the elements to obtain special benefits for special groups of patient needs.
The reality is that for some patients money would have to be paid to them for them to take their medicine. Making it available at little or no cost does in no way help them to understand why they should take it.
Rollo Manning
As a general principle all benefits should be made to fit a program developed with the Indigenous patient as the beneficiary. The PBS contains various elements that can be utilised to suit the need. There is no reason why NGOs such as the Pharmacy Guild, NACCHO or Divisions of General Practice, should be involved in delivering a program that falls within the scope of PBS capability with the elements to obtain special benefits for special groups of patient needs.
The reality is that for some patients money would have to be paid to them for them to take their medicine. Making it available at little or no cost does in no way help them to understand why they should take it.
Rollo Manning
