A RECENT evidence review commissioned by the Department of Health has confirmed what many have known or suspected for some time: the Australian Government has been spending $1.26 billion on community pharmacy programs for which there is “insufficient evidence” to justify their existence. The government can no longer maintain extravagant payments to pharmacy while ignoring high patient co-payments and significant medication issues in Australia.

Australian pharmacy bodies, like their international counterparts, have argued and lobbied for expanding the traditional role of community pharmacists as a health priority for some time. In Australia, $1.26 billion is made available under the Community Pharmacy Agreements for “evidence-based, patient-focused professional pharmacy programs and services”. However, ongoing concerns have been raised in the health policy and medical literature regarding the veracity of the economic and health benefit evidence used for justifying these pharmacy services.

Most clinicians and patients will recognize these services as pharmacist based clinical interventions, residential medication reviews, home medicines review, MedsCheck and Diabetes MedsCheck , staged medication supply, and dose administration aids.

In the 6th Community Pharmacy Agreement (CPA), there was a commitment to undertake effectiveness assessments of the pharmacy programs, with any further funding to be contingent on a recommendation by an independent assessment body. According to the Pharmacy Guild – “The Commonwealth has acknowledged that the likelihood of these Programs being found cost-effective and recommended for further expansion is very high”.

A series of high level independent reports commissioned by the Australian Department of Health, and conducted by the Medical Services Advisory Committee and external company HealthConsult have extensively detailed the lack of evidence supporting some pharmacy services.

Briefly:

The Home Medication Review (HMR) program was designed “to enhance the quality use of medicines and reduce the number of adverse medicine events and associated hospital admissions or medical presentations, by assisting consumers to better manage and understand their medicines through a medication review conducted by an accredited pharmacist in the patient’s home”.  Although home medication reviews had a level of patient satisfaction and adherence, the lack of health or economic benefit was stark:

  • there is insufficient evidence to draw any robust conclusions about the HMR’s effect on adverse drug events or medication-related problems;
  • there is no clear evidence to suggest that an HMR performed by a pharmacist results in an improvement in patient quality of life;
  • there is a lack of a clear evidence base demonstrating an effect of HMR on reducing hospital admissions, care home admissions, or reducing deaths;
  • there is a lack of a clear evidence base demonstrating an effect of HMR on reducing health care service use and costs; there is insufficient evidence to establish the cost-effectiveness of HMRs.

The MedsCheck and Diabetes MedsCheck program was designed to “provide for in-pharmacy medication reviews between pharmacists and consumers to enhance quality use of medicines and reduce adverse events and associated hospital admissions or medical presentations”. Patients were generally satisfied with the service provided, however:

  • there is no positive effect on improving appropriateness of medication prescribing;
  • several included studies addressed the effects of a MedsCheck intervention on intermediate outcomes such as reduction in drug related problems (DRPs); however, improvements in this outcome did not translate to a meaningful reduction in adverse drug events (ADEs) or improvements in any other patient health outcome;
  • the evidence of the impact of medication review performed at the pharmacy on hospital admissions remains uncertain;
  • no effect on falls, conflicting effect on quality of life, no effect on mortality in patients with heart disease;
  • there is a paucity of evidence on the effect of a community pharmacy-based medication review on reducing health care costs.

The Clinical Interventions program, a “specific intervention by a pharmacist, involving identifying, and making a recommendation in an attempt to prevent or resolve, a drug-related problem”.

  • The review was plagued by “insufficient evidence” on all questions the review attempted to answer with respect to improved symptom control and therapeutic response; decreased incidence of adverse events related to medicines; decreased emergency visits and hospitalizations due to DRPs; improved adherence to and concordance with the prescribed medicine regimen; and enhanced knowledge of medicines and disease states;
  • with respect to economic evaluation “… the level of uncertainty in the available findings is too high to make an evidence-based determination regarding the cost effectiveness of the [clinical intervention] service.”

The Residential Medication Management Review (RMMR) – “designed to enhance the quality use of medicines for consumers in approved Australian Government-funded RACFs, by assisting consumers and their carers to better manage their medicines through a medication review conducted by an accredited pharmacist in the RACF”.

  • The “use of RMMR by a clinical pharmacist was associated with an improvement in appropriateness of prescribing, and the identification of medication-related problems”. however, the link between improved medication appropriateness, medication problem identification and patient-related outcomes is not clear;
  • none of the studies determined whether the identification of medication-related problems through the RMMR service led to actual improvements in health outcomes, specifically reduction in adverse drug events;
  • RMMR does not result in a significant improvement in cognitive, physical or behavioural functioning; no fewer falls, no fewer GP or emergency department visits, does not lead to fewer days in hospital; and has no effect on reducing deaths;
  • there is insufficient evidence to assess the effect of pharmacist-led RMMR on quality of life;
  • it remains uncertain whether RMMR decreases medication costs; and
  • no studies were identified that evaluated the cost-effectiveness of RMMR service.

The Quality Use of Medicines program – a component of the Resident Medication Management Review program – was designed to provide support for improved medication management in residential aged care facilities (RACFs). The review acknowledged that although “pharmacists and RACFs participating in the review largely reported that the program was effective and positively impacting on medication management practices within RACFs,” the program:

  • was not explicitly designed to require evidence-based practice;
  • had no program performance indicators and data, and the review team was therefore unable to quantify the extent to which the program was leading to improvements and achieving intended objectives.

Similarly, evidence for the Staged Supply service, and the Dose Administration Aids (DAAs) program was absent or inconclusive.

To summarise, all the reviews were meticulously performed and unambiguous. Contrary to Guild and Government expectations, the evidence for these pharmacy programs was either “severely lacking or inadequate” or confirmed “no benefit”. Not one pharmacy service had conclusive support for clinical and/or economic improvement. The “need for further research” statement was common; however, the “need for further research” is not the standard or justification used for publicly funding health services and programs.

The government can no longer justify the $1.26 billion spent on community pharmacy programs while demanding egregious medication copayments from patients. True pharmacy reform is needed in the 7th CPA to reduce patient medication costs and conserve taxpayers’ money. The question is, how can this be done in an evidence-based way?

More broadly, the evidence reviews exposed the lack of robustness in justifying community pharmacy expenditure in the first instance. Over a billion dollars has been wasted over multiple CPAs financing pharmacist services which have no confirmed clinical or economic benefit. For this reason, independent MSAC review for any new pharmacy service is supported; yet at this point it is unknown if the MSAC has made a formal decision as required under the 6th CPA.

In an era in where governments are divesting funds from low or no value health services, the multibillion-dollar community pharmacy funding cannot be ignored. Government funding for these services should cease, but the divestment should be used to address other medication priorities.

We now have a community pharmacy system that has not delivered medication safety, where medications are delivered in a manner resulting in inconvenience and high costs to patients, and where patients’ prescription co-payments have now risen to over $40 per script. Patient benefit will best be served if these funds are used to address these patient centric problems in the 7th CPA.

The pharmacy sector too, can no longer deny, or paint over the realities; the truths about these services need to be accepted and the profession allowed to move on to new initiatives. At the very least this should facilitate a transition to test new models of care for which the RACGP, the AMA, the Productivity Commission and consumers have been calling.

At present we have a pharmacy funding fiasco, where pharmacy is paid for services without patient or economic benefit; yet real and significant problems with the PBS remain unaddressed. It’s a situation which is no longer acceptable – if it ever was.

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 Royal Australian College of General Practitioners 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 so stated.

 

6 thoughts on “Community pharmacy programs “funding fiasco”

  1. Mick Vagg says:

    The current Pain Medscheck ‘trial’ that is underway is the largest and most expensive research ever undertaken in this country involving chronic pain. The clinical advisory group does not have any input from the Faculty of Pain Medicine. The need for ethics approval was initially overlooked. The service provided as the intervention has no rationale based in current literature to expect that it might work, i.e. there is no clinical equipoise which would make it an ethical trial.

    It’s very hard to escape the conclusion that these incredibly poorly thought out interventions are merely a handout to pharmacists extorted by the Guild in the guise of funding research.

  2. Anonymous says:

    An anecdote as a pharmacist and former pharma-BDM on this subject. Around 2012 when the PBS renumeration to pharmacies was being reduced under EAPD, pharmacy owners were scrabbling around to reclaim lost revenue (which was significant).
    Around the same time the MedsChecks and Clinical Intervention program came in to effect. The program was welcomed as a genuine health-promotion tool, but also as a potential method of recovering revenue lost under EAPD. Mutually beneficial, at face value.
    The commercial team of which I was a member came up with the idea of targetting our brand of atorvastatin in pharmacies as a potential Clinical Intervention – the advantage being that our brand was a calendar pack where as others were not. The rationale and recording of the CI was as a compliance/adherence method – the calender pack ostensibly making things easier for the patient. What wasn’t disclosed was the massively improved margin on our product compared to whichever brand the patient was on previously. Submit the CI paperwork, we find out that each of these CIs was worth a couple of bucks each (initially, it decreases after a while). Add to that the extra revenue from the better product margin, it worked out quite well for some stores.
    These programs will inevitably targeted as a revenue source by a bunch of different stakeholders as the oversight seems to be quite lax. There were reports of pharmacies actively promoting this approach and having suspiciously high numbers of interventions but no evidence of investigation or audit outcomes.
    Retail and healthcare don’t seem to work well together, especially in this environment where pharmacy profitability has been smashed over the last decade.

  3. Dr Juanita Breen (previously Westbury) says:

    Dr Ackermann,

    I am a pharmacist academic. I became accredited to perform RMMRs in 1997 and am very proud to say I performed the very first funded HMR (Home Medication Review) in 1998 as part of a joint Division of General Practice/ University of South Australia trial. I feel I can speak to medication review initiatives.

    What you have failed to note in your opinion piece is that GPs are also funded (in the case of RMMRs, MORE than the accredited pharmacist performing them) to participate in both programs. With HMRs, aside from being funded to consider recommendations, a GP has to initiate them and provide prescribing data. Importantly, no changes to medication can be made without a GP authorising them. Therefore, it is important to stress that GPs are also complicit in the overall effectiveness of medication reviews and potential clinical outcomes that arise from them.

    Both HMRs and RMMRs work best when the prescriber and accredited pharmacist work in an interdisciplinary manner, discussing the medication regime together, with each party valuing the input of the other. In the case of RMMRs, having a nurse present further enhances the process. I have worked alongside many GPs in my 20 years of practice in Australia and in the U.K. and have gained much appreciation of their wealth of diagnostic and clinical knowledge. I have been told by many of the GPs I have worked with that they value my pharmaceutical and therapeutic focus. However, there are many barriers to interdisciplinary practice including time to meet, inconsistent standards of practice and respect for the skills and training of other disciplines.

    An independent qualitative study – with no pharmacist or Guild input – was published last month on the RMMR program. See: https://rdcu.be/bM4Re. It details these barriers to collaborative practice and is well worth reading for another perspective on aspects that impact the effectiveness of RMMRs.

    On a final note, these medication review programs were not conceived as a means to bolster community pharmacy incomes. Internationally, and here in Australia, there is overwhelming evidence of polypharmacy, medication adverse effects, hospitalisation due to medication misadventure, potentially inappropriate prescribing, overuse of psychotropic medication in Aged care (which I have published about in the MJA) and poor adherence. These medication review programs aim to address these issues which result from inadequate prescribing – not from community pharmacy.

  4. Dr Evan Ackermann says:

    Dr Breen – thank you for your considered reply. I focussing on HMR and RMMR you have highlighted the 2 services that would be most confronting to pharmacists. It is not the intent of the article to point the finger to GPs or pharmacists to why they are ineffective, rather to say there is no patient or economic benefit in performing these services. Where and how they work best is irrelevant when there is now over 20 years of research to say they do not work at all.
    It is both fiscally irresponsible (to taxpayers) and clinically irresponsible (to patients) to continue to fund these services in the future.
    I agree with your view, that the health system has multiple medication issues to address. In my article, I support funding to address these problems.
    It is probably the greatest opportunity for Community pharmacy in the upcoming CPA to change. There is now $1B which can be allocated to test/support new models and systems of care, which can address these problems. Will Community Pharmacy take up the challenge?

  5. Anonymous says:

    One respondent’s criticism of the Chronic Pain MedsCheck trial may or may not be valid. However, worth noting that it was designed by HealthConsult, who Dr Ackerman cites as an external company that extensively detailed the lack of evidence supporting some pharmacy services.
    Dr Ackerman highlights “ongoing concerns raised in the medical literature of the veracity of the economic and and health benefit evidence used for justifying these pharmacy services” – the implication being services in the 6th Community Pharmacy Agreement. Worth noting one of the reviews referenced is a Cochrane review from 2010, which supported the roles of pharmacists in patient counselling, therapeutic management, and providing health professional education with the goal of improving patient process of care and clinical outcomes (i.e. educational outreach visits which may impact physician prescribing patterns). The other study based on data from 2004 examined cost-effectiveness analyses on professional pharmacy services (PPS) performed in Europe in order to contribute to current debates on their funding and reimbursement.
    There is more recent and valuable work being undertaken in Australia to determine the impact of medicines review and reconciliation to address the issues as identified by Dr Breen. The Australian context is relevant.

  6. DR Evan Ackermann says:

    To Anonymous 5August 9
    The purpose of including the 2010 Cochrane review was to show even in 2010 – there were a number of issues which stopped reviewers from giving any definitive endorsement for the medication services. That review is of course 9 years old – so the recommendations are dated and apply to circumstances outside the Australian context.

    The purpose and strength of the HealthConsult review was to select studies that were applicable to Australian setting eg pharmacist only medication reviews, in the community etc. This would have included the “more recent and valuable work” you allude to – if in fact it met quality selection standards. This is why the findings have such significant impact – pharmacy cannot gloss over or excuse the results

    In the end -:
    The independent review found no evidence of economic or clinic benefit of the service

    Should Government expend $1.2Billion on services with no health or economic benefit – I suggest not.

    How did the Pharmacy Guild negotiate payment of $1.2B of services without clinical or economic benefit? – We will all have our own answer – but such funding should go through an independent assessment body first don’t you think?

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