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).




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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.

Pharmacists can vaccinate adults against whooping cough, measles and the flu, but it might cost you more



Pharmacist immunisers are gradually being allowed to give more types of vaccines.
FotoDuets/Shutterstock

Catherine Tran, University of Sydney; Clayton Chiu, and Kristine Macartney, University of Sydney

Vaccines have long been available from GPs and nurses. But in recent years, laws have changed to add pharmacists to the list of health professionals who can give select vaccines without a prescription.

This may improve vaccination coverage against the flu, whooping cough and measles. But there’s a chance it could cost you more than if your saw your GP for the same shot.

Overcoming resistance

Before 2014, pharmacists couldn’t give vaccinations in Australia. Then a pilot study allowed a select group of Queensland pharmacies to offer the flu vaccine.

By this time, pharmacists had been giving certain vaccines in Canada, New Zealand, the United States and the United Kingdom for some years.

But in Australia, pharmacists didn’t have the skills and the law didn’t allow it. Another barrier was the attitudes of other health professionals, such as doctors, that pharmacists couldn’t or shouldn’t give vaccinations.




Read more:
How rivalries between doctors and pharmacists turned into the ‘turf war’ we see today


The Queensland pilot study concluded pharmacists could safely and effectively administer certain vaccines to adults, once they were trained. This training included how to administer injections and what to do if something went wrong, such as managing anaphylaxis and performing CPR.

State and territory regulations have changed since 2014 and pharmacist vaccination services have quickly grown. In Victoria, for example, the number of pharmacies registered to give vaccines grew, from 36 in 2017 to 489 in July 2019.

What vaccines can you get at the pharmacy?

The rules vary in each state and territory. Generally, if you’re 16 and over, pharmacist immunisers can give you the following three vaccines:

  • influenza (flu)
  • diphtheria, tetanus and pertussis (whooping cough) – except Tasmania
  • measles, mumps and rubella (MMR) – except Tasmania and the ACT.

These are important vaccines that are sometimes needed if adults missed doses earlier in life or have waning immunity. The influenza vaccine needs to be given every year in a short time frame.




Read more:
Health Check: are you up to date with your vaccinations?


There are some further exceptions.

In the Australian Capital Territory, pregnant women can’t be vaccinated by a pharmacist.

In Tasmania and Western Australia, the flu vaccine can be given by a pharmacist to those aged ten and over.

Pharmacist immunisers are gradually being allowed to give more types of vaccines. In Western Australia, for example, pharmacists can now deliver the meningococcal ACWY vaccine to those aged 16 and over. This vaccine protects against around half of the strains that cause meningococcal disease in Australia.




Read more:
What is meningococcal disease and what are the options for vaccination?


It might cost you more

Some vaccines that would be free from your GP, practice nurse or immunisation clinic will need to be paid for if given at a community pharmacy. That’s because pharmacist immunisers aren’t able to access the government-funded vaccines that your clinic can.

Victoria is an exception – pharmacists can give select government-funded vaccines. And in the ACT and WA, the over-65s can access government-funded flu vaccines at pharmacies.

Pharmacists can’t usually access government-funded vaccines, aside from in Victoria.
Dragana Gordic/Shutterstock

The cost of vaccines at pharmacies varies. In Victoria, for example, the total fee charged for people not eligible for a government-funded vaccination is around A$20 for influenza and A$43 for pertussis (whooping cough).

Even if the vaccine is free, the pharmacy may still charge a consultation fee.

If you see your GP, they may either bulk bill you for the appointment or charge a consultation fee.

The best thing is to check ahead about any out-of-pocket expenses for vaccination when you make your booking.

Do you need to see a GP?

Pharmacy vaccination increases access to preventative health care, especially for those living in rural and remote areas, where it’s difficult to visit a doctor or clinics are infrequent.

Having pharmacists as immunisers also increases the immunisation workforce capacity for public health responses. To help address an outbreak of meningococcal disease last year in Tasmania, pharmacist immunisers administered the meningococcal ACWY vaccine to people aged 10 to 21.

Going to the pharmacist for some vaccines may take some pressure off family doctors and free GPs to deliver more complex care that only they can perform.




Read more:
The role of pharmacists should be overhauled, taking the heat off GPs


But there may be instances when it’s better to go to your GP for a vaccination, for example, if you’re pregnant, have a chronic health condition or need some blood tests related to vaccination. Or you might have other things to discuss with your doctor other than vaccines.The Conversation

Catherine Tran, Senior Research Officer and Pharmacist, National Centre for Immunisation Research and Surveillance, University of Sydney; Clayton Chiu, Public Health Physician, and Kristine Macartney, Professor, Discipline of Paediatrics and Child Health, University of Sydney

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