Working out the funding

I do a little bit of work for APC as a subject matter expert and sometimes also do some education and training with GP registrars. It's a nice mix and keeps me professionally stimulated and certainly very busy.

pharmacists directly. And certainly from my experience, that's what the majority of gps or very large number of gps do today. Obviously going back probably what now, 8, 9, 10 years ago maybe even, we had the introduction of the cap of 20 patients per accredited pharmacists per month, which obviously was quite a disruptor to the service. And I think I certainly know it led to some good pharmacists quitting the industry because it was no longer a viable sole business.

And I feel personally very strongly that that cap is unhelpful. It's not in the interest of patients. Many patients need a timely review and in certain areas, particularly where there's a limited number of providers, it does mean some patients wait longer than they need to get a review. And then obviously the last few years we've seen some further evolution with the good news of a relaxation in the cap. So out from 20 to 30 per month, which was very welcome for busy providers.

And obviously the introduction also of telehealth reviews during covid, which was a fabulous change to the service rules I believe. And I think most credentialed pharmacists would agree it meant Keep providing the service during those tough COVID times. It also meant that for some clients it was great to be able to do follow-ups by telephone as well. And that of course was the other change. The option to provide follow-ups at all was a new development.

And I think a very, very worthwhile one because I think certainly from my experience, and I know many other credentialed pharmacists, a lot of the patients we see are really complex. One of my regular referring GPs has often said to me, she said, I hope you don't mind, but I get you to see all my most complex patients. She said the ones that give me a headache. And you don't fix those medication management problems with one visit.

So having the ability to provide a follow-up or two build that rapport or develop further that rapport with the patient provide ongoing support to the patient, often their carers as well is great. And so I guess we've seen the service evolve. We've seen some steps back with the introduction of caps, some steps forward with the introduction of follow-ups and telehealth and then some steps back again with the cessation of the telehealth option.

But now we face, I think guess a bigger challenge is just the future viability of the service and maybe we'll discuss that further as we go through the podcast.

So for complex patients, particularly if let's say six months has evolved, it can almost be like another full review and that is sometimes a bit difficult to manage what the expectation is. So my own practice, I approach them in different ways who are relatively straightforward. The issue that triggered the referral is I'm reasonably confident is resolved

with that first review. And in those situations, I would usually not expect to do a follow-up and don't, there are some patients who are really, really complex who when you're with them pretty darn well, they're going to need a follow-up. And I'll often discuss that with the patient and in the majority of cases they will acknowledge that it would be good to have that follow up. So we have that discussion upfront. So when I phone them in a few months time, they're expecting that call.

And then there are others who I also sometimes partly put it back to the GP and say, let me know if you want my ongoing input with the care of this patient because I'm able to provide follow-ups For me, pretty much I cap out every month with full reviews. I have for the last two years worked at absolute full capacity with full reviews doing 30 a month, but I probably only do on average about six follow-ups a month.

And that's partly, I'll be honest, my own capacity, but also is that there's some patients for whom you think they will need a follow-up. And it turns out things have gone smoothly. Maybe the changes that were made have been implemented without any dramas. The patient's got a good response, no side effects, et cetera, and you found them and things are going so well and they don't need a follow up. So I think it's a really good option and I think it would be, it's really enhanced the service.

We're no longer just seen as a fly in fly out person. We are there as somebody who gives ongoing connection with the patient. And obviously there's always the option for a GP to re-refer for a new full review. And indeed, for some patients that is needed. I think of a couple of patients I've seen multiple times, one of them who is 42, yes, I said 42 medicines on their GP referral.

Those people typically need a full new referral periodically because the complexity of the health conditions and the medicines they're on a follow-up is not an adequate service to simply make that they need a full new review, in my opinion.

I personally believe that visiting people in their own home is the optimal experience. You build a connection with people, you see things in the home around how medicines are managed, which it's not the same doing that by phone. Most patients who I did a telehealth review with weren't sufficiently tech savvy or didn't feel comfortable using teams or Zoom or FaceTime. So it was literally a telephone conversation.

And I feel it can feel a bit more like an interrogation when you're just having to ask so many questions, whereas when you sat with someone in their home with the medicines on the table in front of you, you can see things and it's a much more natural conversation. That said, I think the demise of the option to provide telehealth is a real shame because for some clients it really was a good option.

And I think for some patients, particularly those who live rural and remotely, the reality is providing a face-to-face follow-up is just not viable. When you think that a second follow-up, particularly the fee for that is $55. If you've got to drive somewhere, sit with a patient, drive home, write a report that really is not viable, and even for some patients first follow up, again, having to do that face-to-face is pushing the limits of viability for providers.

So telehealth was a great option for the right client at the right time, and it's a shame we've lost that option. I'm afraid we'd love it to be reinstated. It'd be great. There.

But the problem is, is that every time CPA is renegotiated, it's obviously a very crowded environment for funding for pharmacy services. And I mean, my personal perspective is that the money that's allocated to the HMR and indeed the RMMR programs is a very small proportion of money of the total. And there isn't a strong voice at the negotiating table where RS and rmrs are the passion for those who are negotiating.

It obviously covers a very wide range of pharmacy services. And so there's a risk, my feel, and I know I'm not alone in feeling this, that the voice representing accredited pharmacists and the gps who use the HMR and our S service and the patients who receive these reviews is a very quiet voice and there's a risk that it gets drowned out amongst bigger ticket items.

So whilst in many ways the arrangement is good, the problem is the fact that CPA negotiations come around every five years, and this is not the first time that there seems to have been a threat to the future of the funding. And it's immensely frustrating, I think, for providers to live by agreement to agreement to not be able to have some security. I've been a pharmacist for 33 years and I've worked in two continents in community, in hospital, in general practice, in academia, in regulatory,

sort of governmental type roles. Now as a consultant. And I find my personal view is that providing in-home clinical medication reviews is for me probably the ultimate definition of pharmacist practicing to full scope, which is something that there's buy-in from professional organizations, even the minister himself as well as individual pharmacists. So I find it quite ironic that we have these discussions every few years around, are we going to have a service to provide, which is,

let's just use the word disappointing. What would I think would be ideal? Well, ideal would be to have indexed payments for the service which we haven't had under 7 CPA bit more flexibility around the way that we can provide services, so relaxation or even abolition of the cap, permission to do telehealth. Again, a bit more flexibility and reasonable reimbursement for rural and remote reviews.

The payment for travel is not intended to cover the entire costs, but it is a barrier to rural and remote patients receiving reviews. So there's a few things that would be great. Firstly, continuation of the services. We know it with funding that rises in line with cost of living flexibility, which helps us better meet patients' needs. But I think there's also a bigger question is, is this the right funding stream?

If we are going to have these threats and discussions and need to mount campaigns every few years, should we be thinking about another funding stream? And there are a number of us who believe that MBS funding would be a good alternative. I mean, I'm not saying that's all plain sailing, but I think it would at least separate us from the crowded space of pharmacy service funding provision that goes with being tied to the CPA.

Another thing which has been brought up by a number of pharmacists, particularly those who work in areas servicing rural and remote patients, is that the whole viability of providing services in those communities, which are often some of our most disadvantaged communities with poor GP services, often indigenous communities and others where the needs are really high, the current arrangements around travel and caps and so on can make it really difficult to viably meet the needs of those patients.

So I think that's the other thing we really would like to see is a little bit more patient-centeredness into the way that the services funded to enable us to best meet patients' needs. Because at the moment, it doesn't always meet patients' needs as well as we'd like. So yeah, I think that's something that would be really good to see.

Often I think a little bit suspicious about petitions and I've certainly heard a couple of comments made that people are a bit wary about putting their name to something, which is really interesting, even some accredited pharmacists. But he was great, got off to a great start. As I say, leveled off. It would be lovely to get a bit more traction again with it. And certainly people who I talk to are very, very supportive of what we're trying to achieve with the ion,

including many patients. Indeed, I feel that, this is really sad to say this, but I have a feeling there's a little bit of fatigue maybe in government around the profession at the moment, and that's sad to have to say that. But the reality is obviously we've had the whole issue of 60 day dispensing with all the ramifications of that which are so profound to the industry. I think it's almost a case of, oh, it's pharmacists again about something else.

What do they want now? So in a way, our timing is really bad because we are coming on the back of another really important topic being discussed with providers. And for that reason, I think it's particularly important with the petition that we get patients and we get gps and we get carers involved and demonstrating their support by signing the petition.

This isn't just about pharmacists who are accredited, who are concerned about their livelihood, those pharmacists that are also concerned about the patients who they care for. But if the government can hear from the patients and carers themselves and the GP community about how much they value the service, that will hopefully make government listen and or make them more likely to listen that this has got a broader ramifications if this service does not continue in a sustainably funded way.

I know GPS who've made representations through their own organizations, the A MA and the R-A-C-G-P, let's not forget the A MA and their submission to the review of the national medicines policy a few years ago made a very strong statement around needing more medication reviews. We've got support. You look at other governmental departments, even the NDIS polypharmacy guidance recommends clients have, participants have reviews. DVA through veterans mates recommend that veterans have reviews.

So you've got all these different bodies, some representing patients, some even representing governmental departments who acknowledge the value of what we do. So you'd like to think that somebody would sit back and go, okay, there's a lot of strong voices here. There's clearly some value in this service. This is something that we should be looking to make put on sustainable footing.

I mean, the other question I sometimes come back to is if we consider a GP referral for A HMR as seeking a specialist's opinion, and let's be honest, we are the medication experts. We go to see people in their home to provide expert clinical advice around the use of medicines. No other referral system from a GP limits how many patients that provider can see in a given time period that provider's own work life balance or whatever may limit it.

But we're not saying cardiology X can only see 30 patients per month. We're not saying this rheumatologist can only see 30 patients a month. So it's just ridiculous in my opinion that we have this cap. And I think again, that's just another element of the service which needs to be challenged.

We appreciate that there will needs to be some checks and balances in the service, but nonetheless, the way it's set up at the moment frustrates both providers as pharmacists, gps as referrers, and the patients and carers who benefit from having the service.

again. So I think the time is ripe now to have a serious look at other funding models and the MBS as one is one which has significant support from a number of people to take us out of that environment of the CPA to put us on a similar footing to other healthcare professionals who have access to the MBS. You think of the different providers who do, I mean a lactation can consultant can claim from MBS for a consult. Why can't a home medicine review pharmacist claim from MBS?

It strikes me as a very inequitable system and one that's, we really need to look at that as a funding model, I believe, moving forward.

for money? It's a fair question taken in isolation. Do we ask whether a consultation with a cardiologist or even a GP or anybody individually as a professional provides value for money? We don't. So I think it is interesting that we have these double standards where we are asked to prove that we provide value for money when other healthcare providers who do a consultation with a patient don't have to provide

value for money. There is an assumption that if patients consult with a specialist, there's value, whether that's a GP specialist or whether it's a disease specific specialist like say a cardiologist or a respiratory physician. So why do we have to answer to that question when no one else does? Controversial? I agree, but I think it's an elephant in the room, which needs to be air.

The other thing is if we get down to the nitty gritty of money, if we reluctantly accept that we have to be cost effective and we appreciate, we do live in a limited cash envelope. From my experience, I think I save the medical benefit, sorry, the health system of Australia, more money on average than I cost it very frequently. Recommendations involve ceasing a medicine that's no longer required, reducing a medicine that carries a risk of medicine's,

misadventure that could cause a hospitalization. We could look at ceasing recommending cessation of supplements which have no evidence base and bring no direct benefit to the patient. We could look at combining medicines into combination products, which actually save money not only for the PBS, but also significant money for the patient themselves. And then the simple housekeeping and education things we do.

One classic example springs to mind for me of a gentleman who I saw a few years ago who'd misunderstood his instructions from his endocrinologist, he'd just been started on insulin and had been told to use a new needle every day. He interpreted a new needle every day as he uses each ryzodeg pen once, injecting 10 units, throwing it away with 290 units still in it through HMR.

Clarification was provided as to what we mean by a new needle that's four and a half thousand dollars a year of Medicare money potentially saved, nevermind him only going to the pharmacy approximately once every eight months rather than once every 25 days. As you got simple housekeeping, things like that. Streamlining, rationalizing things which help patients save money for patients and frequently save money in large amounts of it for the

health system. So yes, we may not have robust cost effectiveness data, but to accredited pharmacists and the majority will tell you they'll all have their own stories as to what we do saves money as well as having direct clinical benefits for patients. So I think there's a number of reasons why we face these threats.

I think there's also some, we don't seem to have support for the service across all professional groups and organizations, which is a great pity because I think when you speak to grassroots pharmacists in whatever sector they're working, most of them are aware of the benefits that RS and indeed Rmrs can provide. So it's interesting.

There's lots of reasons and why I think we have these discussions and threats to the service and I feel some of it's inconsistent and equitable with other health services that exist.

There's quite a lot of NDIS providers, for example, operating group homes who are very aware of the potential benefits for medication reviews and often act as advocates for their participants to get reviews. And I've certainly seen an increase in the number of requests to see people living with disability in recent years. And then the whole general practice pharmacist role. Wouldn't it be fabulous if every general practice in Australia had access to an

embedded pharmacist hands up? I have to admit, I'm biased. I spent nine years in the UK working in roles of that type, probably slightly different focus. The NHS obviously has quite a different way of operating, but nonetheless, the benefits of having embedded pharmacists around quality use of medicines, education, direct patient activities, just a fabulous asset to the health system, if we could get that off the ground.

The thing that I just wonder is I sense there may be some people who perceive if GP practices all had an embedded pharmacist, and obviously it would be pro-rata with the number of gps one assumes, there seems to be an assumption that that would eliminate need for HMR and rmrs. And I could not disagree more profoundly. I think that's completely wrong.

If you look at the average number of patients who attended a typical GP practice and how many are at risk of medicine's misadventure, it would only be possible for a very small number of those people to be serviced by the in-practice pharmacist doing an in-practice review. And obviously there's no funding model for that at the moment at least. So I think it's important to recognize that it's potentially complimentary to the role of HMR and RMMR and disability care pharmacists.

And there may be people who do a little bit of both, but I think we need to be very clear that, and whilst we would love a funding stream for GP practice pharmacists, and I know many GP practices would love there to be one, I don't see that as, it's not an alternative to HMR and R-R-M-M-R work. I think the two compliment each other really nicely.

When you've identified someone taking four antithrombotic who's got a history of peptic ulcer disease and not taking a PPI due to misunderstandings around communication at the transition of care, those sort of big clinical ticket items like that, they stick in your memory forever. But so often it is the more subtle things.

And the thing which gets me every time, and it's happened twice today before recording this, I've done three Rs today and two of those three patients in their own words basically said, how come no one knows about this service? Somebody recently used the word secret service to me. It's just an unknown. People say, and I find that just staggering, but also very sad that we have a nationwide body of a couple of thousand pharmacists who are accredited.

We've got thousands of GPS referring for this service, and we are only scratching the surface of quality use of medicines in the community by providing clinical reviews. Wouldn't it be great if we had a service which was not limited, where people who really needed this service could access it where we had greater uptake in the community and it was no longer a secret service. We have 250,000 hospital admissions a year due to medicines, this adventure,

significant proportion of those potentially preventable. Yeah, it's a crying shame that this service is not optimized as broadly as it should be, but the first challenge we've got is to fight for the service to survive and then build a more sustainable footing for it in the future.