26 July 2017

Why pharmacies won’t accept the status quo

KnowCents Pharmacy

Doctors have declared victory over a couple of industry titans in the latest clash over professional turf with the pharmacy sector.

Sigma Healthcare’s bid to offer unsubsidised pathology services through its Amcal pharmacy chain in a tie-up with the Sonic group came to a dead stop after a deluge of public criticism led by the AMA and – perhaps most tellingly – threats by countless individual GPs to boycott Sonic labs if the plan went ahead.

This decision comes after Sigma ran up the white flag, in March, on a mobile Strokecheck service that was being offered through GP clinics at Amcal stores, after doctors protested that it was causing needless worry to patients.

But the forces behind these latest ructions aren’t going to go away.

Sigma is not letting go of the pathology services plan, for example, saying it will look for another provider.

The $1.3 billion company, one of two drug wholesale giants in Australia which supplies three branded chemist chains and hundreds of independents, is pursuing a strategy to reduce reliance on the dwindling profitability of PBS-related business resulting from the government’s price-cutting.

“While we understand the commercial pressures applied to Sonic and respect their decision, the suspension is disappointing particularly given how hard both parties worked on this Sonic collaboration,” Sigma said, announcing the latest backdown earlier this month.

“The program was developed with a shared objective in line with the Health Department’s initiative to promote in-pharmacy health screening services, with the common goal of identifying at-risk patients not in treatment and referring them into the primary healthcare system.”

The company changed its name from Sigma Pharmaceuticals at its annual shareholders’ meeting in May to reflect its broader ambitions.

Chief Executive Mark Hooper told investors Sigma would continue to embrace its 105-year history while evolving into a “broader and more holistic healthcare business that is built from more than just products”.

“The new name and tagline – connecting health solutions – encapsulates who we are and our aspirations to be a more connected business that values partnerships and the communities in which we operate, and brings integrated and innovative health-driven programs and solutions,” he said.

In its latest reporting year, Sigma raised non-PBS earnings to a level “approaching 40%”, but the goal is to exceed 50%. While details are vague, it has flagged opportunities in chronic disease management, home-based services, over-the-counter sales of health products and vaccinations.

Core expertise

While doctors rejoiced at the collapse of the deal with Sonic, with AMA President Michael Gannon saying pharmacists should “stick to their knitting”, the pharmacy sector appears not to see the status quo as an option.

Dr Shane Jackson, the newly elected president of the Pharmaceutical Society of Australia, says a key issue in the so-called turf wars is that pharmacists’ core expertise in medicines management is undervalued and underutilised by the health system.

“That is where pharmacy struggles,” Dr Jackson, a practising pharmacist and owner with 20 years in the industry, told The Medical Republic.  

“While (pharmacists) have this medicines’ expertise, and we have a massive problem with medications management in this country (leading to) 230,000 hospital admissions costing $1.2 billion a year, the remuneration structure does not support the application of that expertise in a systematic way,” Dr Jackson said.

With accreditation, pharmacists can perform home medicine reviews at patients’ homes or aged-care residential facilities on referral by a GP. But to contain costs, the service is capped at 20 reviews per pharmacy per month, having just been doubled from 10 per month on July 1, a level the pharmaceutical society says is too low to support incomes.

A similar limit of 20 reviews per month applies to in-store MedsCheck and Diabetes MedsCheck programs combined. Under the Community Pharmacy Agreement, pharmacists can qualify for this funding if they provide a separate consulting area to give patients privacy.

MedsCheck, for patients taking five or more prescription medications or who have had a recent significant medical event, carries a benefit of $64.70. For an initial Diabetes MedsCheck, to educate and review medications for diabetics diagnosed within the past 12 months, the fee is $97.05.  For both services, follow-ups are funded at $31.90 and restricted to one per year.

“When your core role is not being funded and recognised adequately, what are you going to do?” Dr Jackson asks. “You look at other things that you are trained to do, but which are not perceived to be within your core focus. I agree our core focus should be medicines management, and I think that should be well supported.”

To GPs and other medical groups, he says he wants to see a cooperative approach to find a sustainable solution.

“If you think pharmacists are encroaching inappropriately on your turf, then sit down and try to work out a structure which applies that core expertise in medication management.”

Another factor is that the accessibility of community pharmacies has led, over the years, to pharmacists gaining formalised skills in triaging patients and treating minor illnesses, for which they are not necessarily paid, Dr Jackson says.

“In my view, our number one role is medicines management; that doesn’t mean the other roles aren’t important and aren’t activities that pharmacists can do. But if your core role isn’t remunerated and structured adequately, especially if you are trying to support the environment and staff you work with, people will look elsewhere,” he says.

“People can come in if they have a concern about their health and get a blood-sugar level or a blood-pressure test, or another type of assessment in the pharmacy, to find out what their risk might be. These are well established and have some evidence base behind them with regards to a trained pharmacist doing them and the outcomes they achieve.

“The key thing is that when you get results that require someone to be referred, that the referral pathway is robust enough to allow that person to enter more formal diagnostic processes.”

Pharmaceutical society guidelines demand that a service should fill an unmet need, and that testing should be appropriate for the setting and for the screening being conducted, questions which are matters of professional judgment and ethics.

“Doing blood-glucose testing, in combination with other screening measures, is an appropriate way to try to find out who the half a million undiagnosed diabetics we have in our country are. Those types of processes are well understood, well respected and appropriate for the pharmacy setting,” Dr Jackson says.

“If the referral pathways are robust, isn’t it better that people with cardiovascular disease and diabetes are identified, so they can be followed up?”

WW1 British Soldier in the trenches in the Somme, France

Pharmacists believe their core role is not being funded and recognised adequately

Broader focus

On the proposal for access to a broader suite of unsubsidised pathology tests at pharmacies, which doctors have criticised as wasteful and catering to the “worried well”, he says services are already available to those willing to pay.

“I think we need to recognise that consumers can have these tests if they choose to. By having some healthcare advice and appropriate process around it, in my view that’s better than having no health assessment associated with the pathology test.

“Having said that, if a person is having testing, as opposed to screening, to monitor an ongoing condition, ideally that should be done within a general practice. That should be well established,” Dr Jackson says.

“But we also live in a consumer-directed world.

“Some people choose to do things they would like to do and are happy to pay for it.  We can’t be so paternalistic that we say you can’t do that.”

Overwhelmingly, Australian consumers are in favour of expanded pharmacy-based services such as vaccinations, an area in which Australia lags far behind North America and the United Kingdom.

The Pharmacy Guild, which represents pharmacy owners as opposed to the society’s focus on professionals, recently claimed a success from an initiative offering influenza vaccines to employees of five Queensland government departments.

In the eight-week program, about 250 pharmacies administered vaccines to 1527 state employees, using a voucher system that gave public servants freedom to choose when and where they had their shots. The result was a revenue gain of more than $41,000 for the pharmacies.

According to a survey conducted for Professor Stephen King’s ongoing Review of Pharmacy Remuneration and Regulation, consumers want to see a broader scope of practice for pharmacists, but with a more clinical focus.

“Across all the scenarios tested in this research, a dispensing or clinic-style pharmacy was preferred, usually by the majority … over a pharmacy environment with an equal or larger focus on retail,” the survey report said.

In its most telling observation, the survey, informed by more than 800 consumers and nearly 1500 pharmacists, found that while the vast majority of customers wanted more advice about medicines from pharmacists they were, on the whole, not willing to pay more for it.

This gets to the nub of the problem. Already, pharmacists perform services every day that are expected by the community but for which they receive little or no reward.

Dr Stephen Carter, a practising pharmacist and lecturer at Sydney University, says a great deal of the work pharmacists do is not properly understood by patients and other health professionals.

Technically, when a pharmacist is asked to dispense a medicine but picks up an anomaly under guidelines or their knowledge of the patient, the pharmacist can make a clinical intervention which is funded under the past two pharmacy agreements.

But Dr Carter says such services are difficult to document and go largely unclaimed.

“These interventions don’t only occur as part of dispensing. In the regular course of the pharmacist seeing people as they walk in, (the decisions) are often in the form of screening or triage roles.”

He evokes the scenario of a patient asking for an asthma puffer.  The pharmacist concludes the patient has not been compliant with other medicines and finds them a doctor. The doctor may or may not prescribe medicine and the patient might, or might not, return to the pharmacy to have it dispensed.

“The pharmacist who made the intervention does not get the recognition for the patient’s health outcome.  There’s no systematised way of that being recognised or paid for, and this happens regularly,” Dr Carter says.

“But every other health provider is paid … such as a nurse in a public health centre or a practitioner in a (medical) practice.”

Over the years, this attention to patients has been cross-subsidised by the pharmaceutical benefits scheme and sales of medicines.  But shrinkage of margins in both areas has put the pharmacist in a tight spot.  The time spent on an intervention might result in a $5 sale, or none at all.

The pharmaceutical society and others are assessing how Australia stacks up against comparable countries, such as the US, the UK, Canada and New Zealand, in terms of the range of vaccines and other services pharmacists can provide, and how the information can be incorporated in electronic health records.

The sector needs to do more academic work on the outcomes of free-market access to pathology tests, Dr Carter says.

The Sonic-Sigma venture was initially supported by the Royal College of Pathologists of Australasia, but RCPA President Dr Michael Harrison backtracked somewhat in response to the AMA’s fury.

As for where he sees pharmacy adding value to the health system, Dr Carter says there’s plenty more for pharmacists to contribute with their “soft skills” in counselling patients about medications and allaying fears of side effects, a main adherence issue, and in opening up conversations about deprescribing.

“Pharmacists do these things every day. But I don’t think the professions realise the impact it could have if those activities were done more and properly remunerated,” Dr Carter says.

Acting Pharmacy Guild President John Dowling says the profession wants to do more in “cognitive services”, shifting emphasis away from supply of medications.

“Supply of pharmaceuticals is an important part of pharmacy, but if we think we can add value elsewhere in the health system and it’s a good use of pharmacists’ time, it helps to diversity the pharmacy business.”