Pay pharmacists to improve our health, not just supply medicines



Pharmacists receive no financial incentive to counsel patients about how to take their medicines. That needs to change.
from www.shutterstock.com

John Jackson, Monash University and Ben Urick, University of North Carolina at Chapel Hill

When you have a medicine dispensed at your local pharmacy under the
Pharmaceutical Benefits Scheme (PBS), two things happen. The federal government determines how much the pharmacy receives for dispensing your medicine. It also decides what you need to pay.

This so-called fee-for-service funding means pharmacies maximise their revenue if they dispense many prescriptions quickly.

Rather than fast dispensing, it would be better for patients and the health-care system if the funding model paid pharmacists for improving the use of medicines, not just for supplying them.

This is possible, according to our research published recently in the Australian Health Review. And it should be considered as part of the next Community Pharmacy Agreement, which outlines how community pharmacy is delivered over the next five years.




Read more:
Explainer: what is the Community Pharmacy Agreement?


Dispensing medicine is more complex than it looks

Dispensing medications may seem simple but this can be misleading: it includes both commercial and professional functions.

Under the PBS, the pharmacy receives a handling fee and mark-up on the cost of the drug to cover the commercial cost of maintaining the pharmacy and stock.

It also receives a dispensing fee for the pharmacist’s professional activities. These include reviewing the prescription to ensure it is legal and appropriate, taking into account factors such as your age, whether you are pregnant and which medicines you’ve been prescribed before; creating a record of the dispensing; labelling the medicine; and counselling you, including providing a medicine information leaflet if needed.

Higher dispensing fees are paid for medicines needing greater levels of security (such as controlled drugs including opioids) and for medicines the pharmacist must make up (such as antibiotics in liquid form).




Read more:
Health Check: is it OK to chew or crush your medicine?


But for the vast majority of PBS prescriptions, a pharmacy receives the same basic dispensing fee, currently A$7.39.

If you have a medicine dispensed for the first time, if it has a complicated dose, or it carries particular risks such as side effects or interactions, a pharmacist is professionally obliged to provide counselling matched to the risk. The more detailed the counselling, the greater the time needed.

However, at present, the dispensing fee to the pharmacy does not change depending on the level of counselling you need. Indeed, the current funding model is a disincentive for the pharmacist to spend time with you explaining your medicine. That’s because the longer they spend counselling, the fewer prescriptions they can dispense, and the fewer dispensing fees they receive.

What could we do better?

Performance-based funding, in which payment is adjusted in recognition of the efforts of the service provider or the outcomes of the service delivered, is becoming more common in health care and can correct some of the volume-related issues mentioned above.

It’s already being used in Australia. For instance, GPs are paid a Practice Incentives Program (PIP) to encourage improvements in services in areas such as asthma and Indigenous health.

However, performance-based funding has yet to be used for pharmacists’ dispensing in Australia.

We propose dispensing fees should be linked to the effort pharmacists make to promote improved use of medicines. This is based on the principle that counselling means people are more likely to take their medications as prescribed, which improves their health.

In other words, pharmacists would receive higher dispensing fees when more counselling is required or if counselling leads to patients taking their medications as prescribed.

Pharmacists who spend longer counselling, for instance if someone’s health status has changed, should be rewarded for it.
from www.shutterstock.com

Dispensing fees could be linked to the actual time taken to dispense a prescription: the longer the time, the higher the fee. The time taken would depend on the nature of the drug; the complexity of the patient’s treatment; recent changes in the patient’s health status or other medicines that need to be taken into account; consultation with the prescribing doctor; and the level of advice and education provided.

A blended payment model could include a fee-for-service payment for commercial processes and a performance-linked payment for professional functions.

The most experience with performance-based payments to pharmacy is in the United States, where evidence is developing of patients taking their medicine as prescribed and lower total health-care costs.

In England, the government’s Pharmacy Quality Scheme is similar to the Australian Practice Incentives Program for GPs. It funds improved performance in areas such as monitoring use of certain drugs and patient safety.

There is some concern about performance-linked payments. Performance targets need to be achievable without being onerous. And performance needs to be clearly linked to the payment being made, but not if other services suffer.

Incentives could apply to you too

Cost is a barrier to some people taking their medicines with over 7% of Australians delaying or not having prescriptions dispensed due to cost.

However, there is currently no financial incentive for you to have a generic (non-branded) medicine dispensed, which would save on PBS expenditure. So it makes sense for generic medicines to be a lower cost to you.




Read more:
Health Check: how do generic medicines compare with the big brands?


There is also currently no financial incentive for you to take your medicine as prescribed, which would likely improve your health and save the health budget in the long run. We are not aware of any country varying patient charges based upon this, although there are ways of monitoring if people take their medicines as directed.

However, countries such as New Zealand and the United Kingdom have lower or no patient prescription charges, minimising costs as a barrier to patients taking their medicine.

What would need to happen?

Dispensing a prescription should be an invitation for the pharmacist to interact with you and help you with advice on the effective and appropriate use of your medicine. At present, there is no incentive, other than professionalism, for pharmacists to add such value.

The proposed changes would require a major restructure to the funding of dispensing to provide incentives that are equitable and transparent and that did not adversely affect disadvantaged, rural and Indigenous people.

There would need to be agreement on reliable and valid performance measures and reliable information systems.

However, funding based on a professional service model rather than a dispensing volume model would support your pharmacist to provide greater benefit to you and the health-care system.The Conversation

John Jackson, Researcher, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University and Ben Urick, Research Assistant Professor, University of North Carolina at Chapel Hill

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Violent Death of Girl in Pakistan Spurs Push for Justice


Rare protest by family of tortured child puts spotlight on abuse of Christian working poor.

LAHORE, Pakistan, January 28 (CDN) — A daring protest and a high-profile funeral here on Monday (Jan. 25) for a 12-year-old Christian girl who died from torture and malnourishment has cast a rare spotlight on abuse of the Christian poor in Pakistan.

In an uncommon challenge in the predominantly Muslim nation, the Christian parents of Shazia Bashir Masih protested police unresponsiveness to the alleged violence against their daughter by Muslim attorney Chaudhary Muhammad Naeem and his family and his attempt to buy their silence after her death. The house servant died on Friday (Jan. 22) after working eight months in Naeem’s house.

An initial medical report indicated she died gradually from blows from a blunt instrument, wounds from a sharp-edged weapon, misuse of medicines and malnourishment. Key media highlighted the case on Pakistan’s airwaves, and minority rights groups along with high-ranking Christian politicians have swooped in to help.

Initially police were unresponsive to the family’s efforts to file charges against Muslim attorney Naeem, and on Saturday (Jan. 23) they staged a protest in front of the Punjab Assembly. The power of Naeem, a former president of the Lahore Bar Association, was such that officers at Litton Road police station refused to listen to Shazia’s relatives when they tried to file a complaint to retrieve her three months ago, telling the girl’s relatives, “a case against a lawyer cannot be registered,” her uncle Rafiq Masih told Compass.

Her mother, Nasreen Bibi, told Compass Naeem came to their home on the day Shazia died and offered 30,000 rupees (US$350) to keep the death secret and to pay for burial expenses.

“I refused to accept their offer, and they went they went away hurling death threats,” she said.

Bibi, a widow who subsequently married a 70-year-old blind man, told Compass that hunger and poverty had forced her to send her daughter to work at Naeem’s house for 1,000 rupees per month (US$12) – the family’s only source of income. Two older daughters are married, and she still cares for a 10-year-old daughter and 8-year-old son living at home.

Rafiq Masih said Naeem illegally kept Shazia at his house, forced her to work long hours and summarily refused family requests to see her. Three months ago, Masih said, Naeem allowed him and Shazia’s mother to see her for five minutes, and the girl complained that Naeem and his son were raping her. Shazia also told them that Naeem, his wife and sister-in-law were beating her and threatening to harm her if she tried to escape.

Enraged, Naeem promptly asked him and Shazia’s mother to leave, Masih said.

“We tried to bring Shazia with us back home,” he said, “but Naeem flatly refused to let Shazia go, and he cruelly and inhumanely grabbed her hair and dragged her inside the house. He returned to threaten us with dire consequences if we tried to file a case against him for keeping Shazia at his home as a bonded laborer.”

Masih and Bibi then went to the Litton Road police station to try to get Naeem to release Shazia, and it was then that duty officers deliberately offered the misinformation that a case could not be made against a lawyer, they said.

A Muslim neighbor of Naeem, Shaukat Ali Agha, told Compass that Naeem tortured Shazia.

“Often that little girl’s cries for mercy could be heard from the residence of the lawyer during the dead of night,” Agha said. “And whenever Shazia requested some food, she got thrashed badly by his wife, son and sister-in-law. One day Shazia was viciously beaten when, forced by starvation, she could not resist picking up a small piece of sugar cane from the lawn of Naeem’s residence to chew.”

As Shazia’s condition deteriorated, Naeem released her to the family and they took her to Jinnah Hospital Lahore on Jan. 19. After fighting for her life there for three days, she succumbed to her injuries and critically malnourished condition, her mother said.

Doctors at the hospital told Compass they found 18 wounds on her body: 13 from a blunt instrument, and five from a “sharp-edged weapon.”

A high-ranking investigating official told Compass that Naeem had given contrary statements under questioning. The police official said that Naeem initially stated that Shazia had fallen down some stairs and died. The police official, who spoke on condition of anonymity, said Naeem quickly changed his statement, saying she had stolen food from the refrigerator and therefore was beaten. The official added that Naeem also said Shazia was insane, disobedient and stubborn, and “therefore she had gotten thrashed and died.”

Doctors at Mayo Hospital Morgue have taken blood and tissue samples from Shazia’s liver, stomach and kidneys and sent them to the Chief Chemical Examiner’s Forensic Lab in Islamabad to determine the official causes of death, officials said.

Family Beaten in Court

On Saturday (Jan. 23) Shazia’s family, along with many other Christians and Muslims, protested outside the Punjab Assembly for three hours, according to rights groups. Key television channels covered police inaction in the face of the violent death, and several high-profile politicians pledged their support, including Pakistani President Asif Ali Zardari. He promised to give the family 500,000 rupees (US$5,835) after Pakistani Minister of Minorities Affairs Shahbaz Bhatti announced a gift of the same amount to compensate the family.

Only after this public pressure did police file a First Information Report, and Naeem and six others, including family members, were arrested earlier this week. Chief Minister of Punjab Shahbaz Sharif reportedly visited the family, promising justice.

The Lahore High Court took up the case on Tuesday (Jan. 26) and ordered police to conclude investigations within 14 days, but none of the high-level action seemed to matter at a hearing that day at District and Sessions Court Lahore, at which Naeem and his accusers were present. As routinely happens in cases where Christians in Pakistan accuse Muslims of wrongdoing, Compass observed as Naeem’s lawyers chanted slogans against Shazia’s family, threatened them and beat them – including Bibi and her blind husband – driving them from the courtroom.

Compass witnessed the Muslim attorneys yelling chants against local media and Christianity, as well. Naeem was neither handcuffed nor escorted by Defense A-Division Police, though he has been charged with murder.

At Shazia’s funeral on Monday at Sacred Heart Cathedral Church, Bishop of Lahore Diocese the Rt. Rev. Alexander John Malik officiated as eminent Christian politicians, human rights activists, Christian clergymen and many others gathered to pay their respects amid heavy police contingents.

After the funeral, her body was taken to her home in the Sammanabad slum of Arriya Nagar, where a throng of neighbors and Christian mourners gathered, chanting for justice. Shazia’s coffin was then taken to Miani Sahib Christian Cemetery, where she was buried amid cries and tears.

Present at the burial ceremonies were Provincial Minister of Punjab for Minorities Affairs Kamran Michael, Federal Minister for Minorities Affairs Bhatti, Christian members of Punjab Parliament Tahir Naveed Chaudhary and Khalil Tahir Sindhu, Bishop Albert Javed, Bishop Samuel Azariah, National Director of the Center for Legal Aid Assistance and Settlement Joseph Francis and other Christian leaders.

In a joint statement issued that day in Lahore, Catholic Archbishop Lawrence John Saldanha and Peter Jacob, executive secretary of the National Council for Justice and Peace, said that Shazia’s death was not an isolated incident, but that violence against the more than 10 million child laborers in the country is commonplace.

Report from Compass Direct News