Issue 45 / 25 November 2013

THE Abbott government wants to make spending cuts across the board. In health this is especially pertinent because of an ageing population and the need to fund new treatments.

Doctors were nonplussed with the previous government’s decision to freeze Medicare rebates until July next year. So far, the new Health Minister Peter Dutton has not reversed the decision.

Pharmacists were also up in arms about a reduction in the price of many commonly prescribed drugs under the Pharmaceutical Benefits Scheme (PBS).

One way the government could reduce the cost of the PBS is to attack the inefficiency of PBS pack sizes and listings.

A common complaint from patients is the confusion and inconvenience created by different pack sizes as they attempt to manage medications. This same complaint is echoed by pharmacies and nursing homes.

In terms of medicines intended for long-term use, the main inconsistency relates to many packs having 30 doses, while others have 28. It may not seem like a big issue, but as the months tick along the medications get out of sync for the patients, resulting in many GP visits just for script renewals.

For instance, statin drugs are in packs of 30, but common antihypertensives are in packs of either 28 or 30. Diuretics are usually in larger packs (eg, frusemide comes in packs of 100), so for many patients one repeat can last for several months.

One pack of aspirin on the PBS lasts for almost 3 months, yet clopidogrel lasts for one.

Antibiotics are another area of inefficiency. The new antibiotic guidelines for simple urinary tract infections (UTIs) in women suggest 3 days of trimethoprim — the PBS pack is seven tablets. Considering UTIs most commonly occur in adult females, wouldn’t a smaller pack make more sense, not to mention save taxpayers a lot of money?

And what about all those antibiotics we want to prescribe for a week, when the pack only allows for 5 days? Doxycycline comes in a number of different pack sizes on the PBS — it is high time some other antibiotics offered such flexibility too.

The standard issue for a strong paracetamol–codeine combination (eg, Panadeine Forte) is 20 tablets, meaning that the standard dose of two tablets three or four times a day allows for the packet to last no more than 4 days. In contrast, oxycodone preparations are in pack sizes designed to last longer.

How is that inconsistency explained given the expense of the oxycodone and its reputation as a drug of addiction and illicit trade?

The future of many cheaper drugs on the PBS should also be scrutinised. The best examples here are aspirin, paracetamol and iron supplements. Patients prescribed these drugs often tell us it is cheaper to buy them over the counter rather than on prescription, even with a pensioner discount.

So if a patient can buy a pack of 100 paracetamol tablets over the counter for as little as $2, why does the PBS pay pharmacies a wholesale price, profit margin and dispensing fee amounting to closer to $8?

It may be impossible to accurately quantify, but I bet that there are thousands of unnecessary GP visits per year — paid for by Medicare — for no other reason than to iron out discrepancies in prescriptions.

A simple solution is to allow doctors more flexibility in prescribing, so that pack sizes are not such a big determinant of prescription quantity and repeats.

Many long-term drugs should be dispensed in 3-month or 6-month quantities without the need to contact PBS authorities.

The reduction in doctor visits and pharmacy dispensing fees would surely make this an ideal way for the new government to rein in health costs.


Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.

7 thoughts on “Aniello Iannuzzi: Simple remedy

  1. Bruni Brewin says:

    Doctors are more than prescription writers.   I have great admiration for doctors and their knowledge.  It wasn’t that long ago I was bitten by something that caused cellulitus and it took three different types of antibiotics to get back on track.  I recently had a cataract operation, where would I be in 10/20 years time if there was nothing available to put that right?  However, there was a time my bloodpressure was very high.  Three lots of different types of bloodpressure tablets over the ensuring months caused such a chronic cough that started from the first prescribing, it took me six months to get over that cough after I stopped all medication.  The last prescription had also made my ankles and knees swell – response from doctor?  “Well, you were allergic to the other two, if this one had been OK, I could have put you on a diuretic to release the odema.”  And if that had given me another symptom?  Yet, my bloodpressure was caused because I was going to bed at 1.30am or even later, not exercising and my body was responding accordingly.  The presciption was given on one blood pressure check.  I have since read that blood pressure should be checked at least over one week at different times of the day – and even on both arms as a great variance between the two arms may indicate heart problems.  I made a decision to go to bed by midnight the latest and do some exercise – the blood pressure went away.  Yet, I have known women who have been on blood pressure medication for years – not one has ever had it suggested that they may now be able to cease taking it.  Sometimes as patients we need some commonsense knocked into our head – not a pill.

  2. University of Tasmania says:

    Perhaps Aniello, we need to take a step back and examine why we give our patients so many medications in the first place.  Every day in the Emergency Department I see frail, elderly patients on a plethora of medications – sometimes the effects of which have led to their visit to the ED, often complicating the management of their various co-morbidities, and, if not causing a problem, usually blindly continued without questioning the necessity of it in the first place.  When you are elderly, frail, at risk of falls and one of life’s few pleasures is having foods you enjoy, does it really matter if you have asymptomatic atrial fibrillation or mild hypertension or hyperlipidaemia or newly discovered impaired glucose metabolism? 

    Oh and by the way, the 8th, 9th and 10th medications prescribed are always an antidepressant, an antiemetic and a PPI.

  3. Anthony Zehetner says:

    Some valid points Aniello. However don’t fear because pharmacists now have the authority with Continued Dispensing to prescribe PBS subsidised pack-sizes of statins, oral contraceptive pills (and soon COPD) medications without the need for a GP (though they’ll let you know).

    It’s about time that the modern medical profession takes back ownership of their patients and reviews their prescribing habits and care plans. If doctors’ only perspective on medication is supply (and not monitoring, interactions, etc), then we deserve to hand over to the pharmacists. 

  4. Philip Dawson says:

    I agree, with reservations. I wouldnt be in favour of larger pacls of analgaesics. if you want more than 20 either prescibe 50 panadeine forte privately (reimbursable for work and road  injuries) or get an authority. For the difference between 28 and 30 pills in a pack, patients on both statins and antihypertensives, just check your computers lapse date at each visit and make sure they have enough till your next scheduled visit, avoiding unnecessary visits and phone calls for scripts. For the confused eg stroke, brain injury dementia, get in early and prescribe a webster pack, then you know they are getting the pills dispensed as prescribed. Computerized software means the prescriber can easily keep tabs of when scripts run out, much better than the days of shuffling through paper to see when you last prescibed it, if you remembered to write it down!

  5. Dr. Adrian R. Clifford says:

    I also agree wholeheartedly with Aniello’s suggestion.  As a taker of multiple prescriptions day & night, how much simpler would it be to go to a pharmacist once a month and get all my tablets to last for the whole month, rather than what I have to do now and go twice a month because I have run out of one or more of my pills!

  6. Graham Row says:

    Aniello your comments are very valid.  Meeting the diverse dosing, packaging and labelling requirements required by diverse governments must also be an expensive headache for pharmaceutical manufacturers. Oh for the days when the pharmacist would count the pills from his large jar into a neat packet and seal it with a little sealing wax or emerge from the back room with your prescription neatly corked and labelled as if by magic.  Away with your new fangled  tamper-evident packaging  and use-by-dates and bring back button boots I say.

  7. Parth Shah says:

    I agree with you Aniello, there is a lot of inconsistency with medication packaging and the intended or desired prescribing by doctors. It would be interesting to analyse how much money would be saved if your suggestions were able to be implemented!

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