Imagine this, here is your medication for the year. Now imagine if you get two slices of cake instead of one? You will only need to go back for more cake six times a year rather than 12, but you still get the same amount of cake.
Cake is probably not a good analogy as some people may choose to eat it all at once!
Back in August 2018, the Pharmaceutical Benefits Advisory Committee (PBAC) was asked to consider two matters
- increasing the supply of some medication to 12 months instead of the current 6 months, and
- to increase the maximum dispensed quantity from one month to two month’s supply.
Following discussion, PBAC recommended, based on both clinical safety and cost-effectiveness, that 143 medications used to treat stable chronic conditions (eg., heart disease, hypertension, dyslipidemia, HRT, glaucoma) would be suitable for 60 day supply. PBAC also acknowledged the financial and convenience benefit for patients. The choice of writing 30 or 60 day prescriptions would be left to the prescriber.
Research suggested that longer prescriptions may improve compliance. This systematic review by King, et al in 2018 concluded “There is insufficient evidence relating to the overall impact of differing prescription lengths on clinical and health service outcomes, although studies do suggest medication adherence may improve with longer prescriptions.” This makes sense if you run out medication then the inconvenience of getting more may outweigh the decision to continue. A study by Batal, etal from Colorado in 2007, found 60-day statin dispensing produced lower lipid levels compared to 30 day dispensing. Every time you run out of medication there is an opportunity to make it permanent.
So what happened to 2018 recommendation?
In 2019, on the back of Pharmacy Guild lobbying, the then Health Minister Greg Hunt scrapped the plan. The Guild was worried about loss of dispensing fees and less frequent pharmacy visits. Just to be clear the Pharmacy Guild is a lobby group representing the financial interests of retail pharmacy owners.
Reported in the Sydney Morning Herald of March 2019 “
“In a strongly worded email to members on Wednesday night, the Guild’s president George Tambassis said the changes would have “a devastating impact on the viability of community pharmacy businesses” and came “without any consultation”. The Guild, according to The Herald Sun last week, had apparently been so enraged by the 60 day dispensing threat, it donated $250,000 to the Victorian branch of the ALP and asked it be used to fund a campaign against Mr Hunt in his Flinders electorate during the 2019 Federal election.
How can the Pharmacy Guild have such a sense power with politicians? Some would say it due to donations to political parties. This article “How and why the Pharmacy Guild is so good at leaning on politicians” documents the amount of donations in 2020 to be $770,000. This is to both the major political parties, and some of the minor parties such as One Nation and Katter’s Australian Party. This article in The Conversation looks further into the history of the Pharmacy Guild lobbying politicians.
Move ahead to 2023, and 60 day dispensing is back in the news. In fact come September 1st, it will become a reality for some PBS prescriptions as announced by the Labor Health Minister Hon Mark Butler. He goes on to say,
“This reform delivers important cost of living relief to Australians, and every dollar saved by the Government will be reinvested straight back into community pharmacies to secure the ongoing strength of the sector and ensure our trusted pharmacists play an even larger role in the healthcare of Australians.”
This means that instead of paying the monthly dispensing fee of $7.82 paid every month to the pharmacy, it will be paid every 2 months. This is a saving of $46.92 over 12 months. Several articles suggest the savings for an average patient will be $160 per year
The Consumer Health Forum of Australia think it a good idea, “Every dollar saved at the pharmacy is money that can be spent on groceries or rent.”
If you listen to the propaganda from the Pharmacy Guild, this simple change is expected to cause the sky fall in the pharmacy in Australia. For examples, closure of pharmacies, loss of 100’s of jobs, further shortages of essential medication, hoarding, increased wastage of medication, increase in overdoses, in fact the current Guild president, Trent Twomey, has even, tearfully, expressed his feelings about an uncaring Government.
Now thinking through some of the Guild claims
60 day dispensing is only an option for stable and chronic medication. Patients will not get 60 days of antibiotics and analgesia. Anyone who prescribed 60 days of antidepressant medication to a patient who is suicidal is likely to be in hot water.
I know from my previous job in a Poison Information Centre, that small children do occasionally get into a grandparent’s medication cabinet. To minimise harm, medication is required to be supplied in a child-proof containers or blister packs. Most grandparents know to keep medication safe from small visitors. Have a read of this article from the Raising Kids Network if your need a reminder. If you want to make your house even safer read this Safety Checklist from the NSW Poisons Information Centre.
Hoarding already happens, clearly shown in this photo of someone’s mediation form a home medication review pharmacist visit.
I have also seen medication wastage when people return unused bottles of medication no longer required. The RUM Project do a great service removing unwanted medications from home medication cabinets. Inevitably, there maybe some increase in wastage of medication needs to be changed. That is why the 60 day dispensing applies only to stable and chronic medication. Returning to evidence, King et al study did suggest there is “some evidence from six studies that longer prescriptions are associated with increased medication waste, but the results were not always statistically significant and are of very low quality.”
What can be done to prevent it? I can look at MyHR and if I see 25 dispensings in 12 months, I can ask the patient why? Can’t this be checked at the time of dispensing? I can ask a patient to bring in all their tablets when I do a care plan review. When I do, I often get a surprise to discover the number of often costly herbal, vitamins alternative medication a patient may also be taking. And yes, sometimes multiple boxes of the same medication.
How to overcome hoarding? Should patients pay more for medication, obviously not a popular suggestion given the patient contribution has only been dropped $30. Highlighting the actual cost of medication may make patients respect the value of medication.
I do think that seems wasteful to just throw away these medications. Maybe we need to rethink this strategy, after all if a capsule or tablet is still in date and sealed in a blister pack surely it can be reused. If the is returned there is the ethical dilemma is can a pharmacist resell it to someone else? There is also the unsolved historical tampering of Tylenol capsules with potassium cyanide back last century.
Surprisingly, your doctor can already prescribe 60 or 90 or 120 days (or more) of medications. You can already get four months of the oral contraception on a PBS prescription. Some medication may be cheaper to get as a private prescription in 60 days or more pack size. For example Chemist warehouse will sell 30 Omeprazole for $7.99 whether you have a private or PBS prescription. So for medication which are under the $30 threshold, a private prescription may be a cheaper alternative.
The specter of empty shelves has been raised. But come September 1st, there will be no tsunami of new prescriptions when everyone comes in with a 60 day prescription. As Minister Butler points of the 325 medicines affected “only seven of them are experiencing supply shortages” Today, I prescribed 12 acute care scripts and 16 chronic disease scripts of which 14 would be suitable for 60 days supply, and 4 Webster scripts which where it wont make a difference to stock levels. That was a typical day prescribing for me.
For an explanation as to why Australia has drug shortages this article form the Medical Republic discusses where we sit in the global pharmaceutical supply chain. In October 2022, the PBS introduced a Medicines Supply Security Guarantee. Manufacturers will be required to hold a minimum of either 4 or 6 months’ of stock in Australia. The 60-day dispensing change may mean that this may strategy need to be tweaked.
60 day dispensing means less foot traffic which may less opportunity for those incidental sales. But if you really need a hair dye, perfume or vitamin you can always make another journey. Have you ever wondered why the retail pharmacy dispensary is at the back of the shop? It’s a bit like Coles and Woolworths putting the milk against the back wall. You have to pass claustrophobia-inducing aisles of shampoo, dental treatments, toilet paper, nappies, hair dyes and vitamins before you get to the dispensary. IN many pharmacies you then have to walk back to the front counter to pay. Did I forget the sunscreen? Pharmacy makes profit on more than just dispensing, in fact given the size of the shelves in some, I think that the front of shop provides more profit.
The Pharmacy Guild of Australia has conducted a financial analysis on the the lost profitability and estimate $170,000 per annum will be lost. I’m not convinced that loosing $46.92 over 12 months per patient really equates to that. I doubt their workings will be made public.
Someone suggested that the pharmacies will need to but an extra fridge and expand dispensary shelves. There is a small number of medications on the PBS list that need to be kept cold, correct me but I spotted dulaglutide and semaglutide (which are routinely in short supply) and calcitonin and teriparatide injections (which I have never prescribed)
Patients who are disabled, don’t have access to transport or distant from a pharmacy will be grateful they don’t have to make a monthly journey for medications.
By reducing the daily dispensing load, pharmacists will have a greater opportunity to do the things they have been trained for – to discuss medication with the patient and deal with the simple health problems that people visit a pharmacy for.
Will retail pharmacists go broke and sack 100’s of works as having been suggested by a number of pharmacists and the Guild? The Seventh Community Pharmacy Agreement has a clause which provides safety net to these small businesses called the Remuneration adjustment mechanism. This was negotiated in 2020 and is set to run until 2025. I am not sure if these are any other small businesses in Australia who have a similar safety net. No adjustment was required in 2022–23 as the number of prescriptions was within 5% of estimated prescriptions.
Maybe there are too many pharmacies in some areas of Australia and the economic challenge will cull those with marginal profitability?
I do some issues which are surmountable;
- updating prescribing & dispensing programmes with the new 60 day option
- Manufacturers increasing pack sizes
- Confusion for some patients on polypharmacy who have some medication in 30 days supply and some in 60 day supply
None of these are a roadblock to health care savings for those on multiple medications.
The good news is 90 days dispensing is not on the cards. Minister Butler has brushed this suggestion aside at least for the time being.
To end a reassuring message from Chief Medical Officer, Professor Michael Kidd
Mark Raines 