WITH “standard costs” for dispensing prescription drugs again rising from 1 January 2019, it is time to cease an anomaly which increases costs and inconveniences patients without any health benefit.
The Pharmaceutical Benefits Scheme (PBS) requirement that dictates monthly medication dispensing for many long-term health conditions is an anachronism that needs to go. The evidence available favours longer prescription durations for selected chronic conditions for both health and financial outcomes. It is time to consider 3- or 6-month medication supply for many of these chronic diseases, and transfer savings from excessive pharmacy fees back to patients.
The monthly trip to the pharmacy for long term medication repeats is a well-known experience for many people. The inconvenience, the time, the travel, the script, the wait, the fees …. repeat medications are the unforgiving burden which make the community pharmacy a frequented establishment. It has been described by patients and carer’s as “the recurring hassle”.
Being on long-term medications is now the norm for many Australians. Medications for blood pressure, cholesterol, heartburn and first-line diabetes therapy are the majority of the top 10 drugs by prescription counts and drug quantity in Australia, and constitute a large percentage of drugs delivered to the community.
From a quality of care perspective, it is questionable whether the current standard monthly supply for chronic disease management is the best method to deliver medications efficiently and effectively. Is a 1-month supply of medication better than say, 3, 4 or 6 months, as is available for hypothyroid medication or the oral contraceptive pill?
Recent evidence reviews (here, and here) give consistent findings that there is very little support for monthly medication supply. Longer prescription lengths are associated with lower costs, better compliance and higher quality-adjusted life-years. Concerns that longer dispensed drug durations result in increased costs from medication waste also proved unfounded. Evidence that added waste occurred was inconsistent, and costs were more than offset by lower dispensing fees and time savings for both practitioners and patients.
With these medications, there is overwhelming evidence that medical supervision and treatment result in improved patient outcomes, but the rationale for lifelong pharmacist involvement every month is unclear. Currently, there is no evidence of clinical or other benefit from going to the pharmacy on a monthly basis to obtain these medications.
Increased drug supply is clearly not suitable for all chronic disease medications; antipsychotic agents, analgesics and other expensive drugs being examples; but for a sizable proportion of chronic disease management, longer prescribed medication supply is safe and appropriate. In Canada, maintenance drugs for long term conditions are encouraged and already being dispensed in 100-day supply. There is no reason Australia cannot adopt a similar policy.
With chronic disease medications topping the prescription counts in Australia, the savings to the health system in dispensing and administrative fees would be considerable. The opportunity to pass these savings on to patients should be undertaken, given serious cost problems now faced by patients for health care.
The main obstacle to this reform is pharmacy. Loss of revenue from prescription, administrative and handling fees would be significant. If you went to a chemist today and got 3 months’ supply of a drug, they can charge you three times the drug cost and three times the markup on the drug, plus three times the administration fees and three times the dispensing fees. Under the new proposal, they could charge three times the drug cost and markup, but only charge you once for the dispensing fee.
Pharmacy may well invent any number of reasons why this change should not be implemented, but the PBS was introduced for efficient and effective delivery of medications, not to sustain the business models of pharmacy. If two-thirds of medical visits were demonstrated to be unnecessary, there would be a major review and immediate change to clinical practice. Pharmacy should be no different.
In an efficient health system, the quantity and interval of repeat prescriptions should be evidence-based and should balance patient safety with clinical appropriateness and cost-effectiveness. This is not currently happening. The practice of routine monthly supply of medications simply increases costs and inconveniences patients without any health benefit. High prescription numbers place an unnecessary workload on pharmacists, which is associated with dispensing errors.
With health costs likely to be one of the major election issues, it is time to revisit reforms which decrease patient costs and improve outcomes. Addressing the costs of “routine” medication repeats and intervals should be a priority.
Dr Evan Ackermann is a GP on the Gold Coast. He has a long term interest in safety and quality issues, and is immediate past Chair of RACGP Expert Committee Quality Care. You can find him on Twitter @EvanAckermann
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless that is so stated.