Home medicines reviews show no evidence of benefit, yet they continue to be funded without being held to quality standards.
Accredited pharmacists can claim $222 from a single home medicines review.
They can claim another $111 if they follow up with the patient, another $55 if they follow up a second time, and more than $100 extra weekly pay as long as they’re qualified to do them.
Nice work if you can get it – especially for a service found by an independent review to provide no clinical or economic benefit. But what happens when something goes wrong?
In early 2020, almost one year on from a heart attack, semi-retired NSW pharmacist Theresa Kot found herself on seven different medications and experiencing symptoms which her GP felt could be indicative of an adverse drug reaction.
She was referred to a community pharmacist for a domiciliary medication management review.
When Ms Kot read the report which the pharmacist submitted back to the GP, she was disturbed to notice several errors, ranging from poor grammar, unintelligible sentences and confusion as to her sex, to a suggestion that she be put on antidepressants to help curb sudden weight loss.
“She has a good understanding of her medication due to her background as a pharmacist, however as a fact as the patient will read more about all the facts, side effects and researches sometimes he will not be able to cope very well with his medication regimen,” one sentence reads.
The pharmacist also missed the fact that Ms Kot’s GP had written down the dosage of one her medications wrong.
“There is work being put out [at a low standard], and it then falls on the GP to assess whether that report has relevance or not,” she told The Medical Republic.
“That to me is a shortcoming because now you’re making [a GP] responsible for that work and yet the government is paying [the pharmacist].”
But getting her concerns with the report acknowledged turned out to be harder than she anticipated – partly because, as her GP told her, it was actually quite good by their standards.
Who can do a medication review?
Home medicines reviews can be completed by any registered pharmacist who has completed a multi-step training program.
After doing an initial preparatory course, accreditation hopefuls must pass a communication module and a clinical multiple-choice questionnaire before moving on to a final assessment of three case studies.
Once accredited, pharmacists must do yearly CPD to maintain their status.
“It’s a quite an involved process, it usually takes people between six and 12 months to do,” University of Sydney pharmacy lecturer and Australian Association of Consultant Pharmacists chairman Dr Stephen Carter told TMR.
“At the end of it, we provide them with a certificate, which they can keep up to date by doing 60 [CPD] points each year, and then every three years sitting a multiple-choice question exam.”
The process isn’t cheap – application fees sit at around $872, accreditation fees cost another $857 and reaccreditation is around $670 annually.
Still, once a pharmacist is accredited, they can do up to 30 home medicines reviews per month and charge $222 for the initial patient interview, assessment and medicines report, then claim for follow-ups.
The payments are funded not through Medicare but via the Community Pharmacy Agreement negotiated between the Pharmacy Guild and the government, now in its seventh incarnation.
Other programs funded under the CPA are the MedsCheck and diabetes MedsCheck, clinical interventions, residential medication management review, quality use of medicines, staged supply service and dose administration aids.
When the Medical Services Advisory Committee reviewed the programs funded under the CPA in the leadup to negotiations in 2019, it found that none of these programs showed clinical or economic benefit.
When a pharmacist is accredited to do HMRs, their employer has to pay them an extra $106.40 per week, after the Fair Work Commission decided this would be a suitable allowance for having a higher qualification.
Patients are eligible to receive a home medicines review if they are at risk of “experiencing medication misadventure”, live in a community setting, are referred by a medical practitioner and hold a Medicare card.
People who are at risk of medication misadventure include those who are taking more than five medicines per day, are recently discharged from hospital, have had recent changes to their medication or are confused around which medicines they are taking.
Dr Carter said that, ideally, home medicines reviews were a collaborative process in which a patient’s GP and pharmacist worked together to identify and resolve any issues.
Of course, it doesn’t always turn out that way, since follow-ups with the GP do not attract payment.
“Getting those case conferences done is tricky, and I think that’s an area where we don’t see pharmacists and GPs working together as [often as they should],” he said.
“I think one of the structural barriers to that is that pharmacists aren’t generally included on the MBS, so they can’t really claim for extra payment through follow-up case conferences.”
The complaint-submission odyssey
Ms Kot, whose background as a pharmacist is in poisons control, wanted to put in a complaint about the home medicines review report the pharmacist prepared.
First, she went to the Health Care Complaints Commission, which referred her to the Pharmacy Council of New South Wales. They assessed her complaint, but she was not satisfied.
“They wrote back and said, ‘we don’t have any problem with the work’,” Ms Kot told TMR.
“So I did an appeal, which basically came back the same.”
Next stop was the GP who had referred her for the medicines review in the first place.
According to Ms Kot, her GP essentially told her that the report was of a higher quality than she normally received, and she did not share her patient’s concerns.
Ms Kot then tried the body which accredits pharmacists to do home medicines reviews, the Australian Association of Consultant Pharmacy.
No dice – while the AACP manages training, investigating complaints like Ms Kot’s is not in its remit.
Her final call was to the Pharmacy Programs Administrator, the agency responsible for administering, processing and paying claims for all community pharmacy programs funded under the Community Pharmacy Agreement.
This body also had no scope to act on Ms Kot’s complaint.
According to Dr Carter, who is familiar with Ms Kot’s case, even a poor home medicines review is relatively unlikely to harm a patient.
“It’s potentially possible [for the pharmacist to make a harmful recommendation],” he said.
“Luckily, there’s that collaborative oversight with the GP, who ultimately takes responsibility for implementing a medication management plan.”
Dr Carter said that, while it was unfortunate, human error means that mistakes do happen.
“As in every health discipline, there will be times when people aren’t working at peak performance or demonstrating the highest level of competency every time,” he said.
“It’s really a shame when it causes harm, but I don’t believe in this case there was any harm resulting from it.”
While the low-quality review she received left her unharmed, Ms Kot worries about how easily her complaint was brushed over, given the other incoming expansions to pharmacists’ scope. Ms Kot was prompted to call TMR about the experience when she read about the North Queensland Pharmacy Scope of Practice Pilot.
“I went through a process where the Pharmacy Council of NSW said, ‘oh, but [your complaint is] piddle, we’re not worried about that’,” she said.
“How are they going to do this at the much higher level of medical conditions?” she said. “[Are they] going to say, ‘oh, well, the pharmacist made a small mistake and it’s not a problem’ then?”
