tag:theconversation.com,2011:/ca/topics/pharmacy-guild-1707/articlesPharmacy Guild – The Conversation2023-05-01T20:01:20Ztag:theconversation.com,2011:article/2040282023-05-01T20:01:20Z2023-05-01T20:01:20ZHere’s why pharmacists are angry at script changes – and why the government is making them anyway<figure><img src="https://images.theconversation.com/files/523557/original/file-20230501-28-rxhhxq.jpg?ixlib=rb-1.1.0&rect=70%2C0%2C6639%2C3370&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/female-pharmacist-protective-mask-on-her-1734593969">Shutterstock</a></span></figcaption></figure><p>Australians will <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-care-press-conference-26-april-2023?language=en">soon be able to fill</a> two months’ supply of medicines at their community pharmacy, rather than one, for 325 common medicines. This change is expected to halve the cost of prescriptions for six million Australians.</p>
<p>The Pharmacy Guild of Australia has taken exception to the government’s policy change, <a href="https://www.guild.org.au/news-events/news/2023/8-in-10-australians-reject-federal-budget-proposal-due-to-medicine-shortages">warning</a> it will create medicine shortages and make pharmacies financially worse off.</p>
<p>The president of the guild <a href="https://www.sbs.com.au/news/video/pharmacy-advocate-in-tears-over-prescription-changes/mu92ka0aq">wept</a> at the thought of pharmacies going under because of reduced income from dispensing fees and co-payments. </p>
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<p>Mark Butler, the federal minister for health and aged care, was deft in his response, <a href="https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-care-press-conference-26-april-2023">advising Australians to</a>: </p>
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<p>take advice around medicine supply and medicine shortages from our medicines authorities rather than the pharmacy lobby group.</p>
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<p>This argy-bargy between the government and the guild is not uncommon.</p>
<p>What is uncommon is the public dismissal from a health minister of the guild’s views. This government is using its political capital to push health reform forward and doesn’t seem afraid to ruffle a few feathers.</p>
<h2>What is the Pharmacy Guild of Australia?</h2>
<p>The guild is an <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4605468/">influential peak body</a> registered under the federal Fair Work Act 2009. It acts like a union for community pharmacy (also known as chemists) owners. It provides resources to help pharmacists improve their small businesses, but most of its membership value comes from advocating for community pharmacy owners.</p>
<p>The Pharmaceutical Society of Australia is a separate group which represents all pharmacists, including those who work in hospitals and those who don’t own the pharmacy they work in.</p>
<p>The guild and the Pharmaceutical Society of Australia negotiate five-year agreements with the government on remuneration and funding for supplying Pharmaceutical Benefits Scheme (PBS) medicines in the community and for delivering pharmacy programs to support patients.</p>
<p>Known as <a href="https://theconversation.com/explainer-what-is-the-community-pharmacy-agreement-38789#:%7E:text=Patients%20pay%20a%20contribution%20towards,patient%20contribution%20from%20the%20government.">Community Pharmacy Agreements</a>, the first was signed in 1990, while the most recent seventh Community Pharmacy Agreement was signed in 2020. That agreement is due to expire in 2025, potentially costing A$25 billion over five years. Of this, $16 billion will be paid for by the government and $9 billion will be paid for by patients.</p>
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Read more:
<a href="https://theconversation.com/explainer-what-is-the-community-pharmacy-agreement-38789">Explainer: what is the Community Pharmacy Agreement?</a>
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<h2>How does the guild wield its power?</h2>
<p>The guild is nearly 100 years old. It understands health care and how health policy is made. It has a reputation for shaping government health policy envied by many a health care peak body.</p>
<p>It doesn’t have authority over government policy. It asserts its influence through its soft power by shaping community preferences to get patients behind what it wants. This stems from community pharmacy’s reach into every corner of Australia and the inherent trust between a pharmacist and a patient. It undertakes its own research to generate ideas and to criticise government policy when it suits.</p>
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<img alt="Pharmacist explains a medicine to a mother holding a young child" src="https://images.theconversation.com/files/523560/original/file-20230501-28-swsnio.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523560/original/file-20230501-28-swsnio.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523560/original/file-20230501-28-swsnio.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523560/original/file-20230501-28-swsnio.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523560/original/file-20230501-28-swsnio.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523560/original/file-20230501-28-swsnio.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523560/original/file-20230501-28-swsnio.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Pharmacies are found in all corners of the country.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cheerful-pharmacist-chemist-woman-giving-vitamins-211739305">Shutterstock</a></span>
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<p>The guild also takes a more direct approach to influencing government policy. The Australian Electoral Commission <a href="https://transparency.aec.gov.au/Donor">reported</a> the guild was the 13th largest political donor in 2021–22, donating $578,000 to political parties across 88 separate donations. This was in an election year, which almost doubled its donations compared to the previous year.</p>
<h2>What policies has the guild influenced?</h2>
<p>The recent extent of the guild’s power is reflected in favourable policy outcomes for community pharmacies, despite these sometimes being unfavourable for taxpayers or patients.</p>
<p>The guild convinced the government to provide community pharmacies and pharmaceutical wholesalers with <a href="https://archive.budget.gov.au/2017-18/bp2/bp2.pdf">an extra</a> $225 million in the 2017–18 budget because prescription volumes were lower than expected within the sixth Community Pharmacy Agreement. This was a simple cash grab by pharmacies from taxpayers.</p>
<p>The guild also won a contentious policy back-flip in 2018 by getting the government to retain the Pharmacy Location Rules, <a href="https://www.guild.org.au/resources/business-conditions-survey">arguing</a> they provide “certainty and stability” for pharmacy small business. </p>
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Read more:
<a href="https://theconversation.com/what-is-the-pharmacy-guild-of-australia-and-why-does-it-wield-so-much-power-127315">What is the Pharmacy Guild of Australia and why does it wield so much power?</a>
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<h2>What are the Pharmacy Location Rules?</h2>
<p>The Pharmacy Location Rules are an <a href="https://www1.health.gov.au/internet/main/publishing.nsf/content/DDB409EBB18FCE8FCA257BF0001D3C0C/%24File/Pharmacy-Location-Rules-Applicants-Handbook-October-2018-v1-1.pdf">agreement</a> between the Australian government and the Pharmacy Guild of Australia. They place restrictions on where a new pharmacy can be established or where an existing pharmacy can be relocated. Pharmacies must meet location based criteria to be approved by the Australian Community Pharmacy Authority to receive pharmaceutical benefits. </p>
<p>The Pharmacy Location Rules <a href="https://www1.health.gov.au/internet/main/publishing.nsf/content/DDB409EBB18FCE8FCA257BF0001D3C0C/%24File/Pharmacy-Location-Rules-Applicants-Handbook-October-2018-v1-1.pdf">do not allow</a> new pharmacies to open within 1.5 kilometres or 10 kilometres of an existing pharmacy depending on the location, distance to the nearest pharmacy, and the number of supermarkets and medical practitioners in the area. Unless exempt, they do not allow pharmacies to be relocated from the town in which the approval was originally granted.</p>
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<img alt="shelf of common medicines" src="https://images.theconversation.com/files/523562/original/file-20230501-26-61xeda.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523562/original/file-20230501-26-61xeda.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=445&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523562/original/file-20230501-26-61xeda.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=445&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523562/original/file-20230501-26-61xeda.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=445&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523562/original/file-20230501-26-61xeda.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=560&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523562/original/file-20230501-26-61xeda.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=560&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523562/original/file-20230501-26-61xeda.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=560&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The Pharmacy Location Rules determine where new pharmacy retailers can set up.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/pyuOXgO951U">Unsplash/Franki Chamaki</a></span>
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<p>While no research has directly examined the impact, this policy has likely inflated consumer costs due to a restricted competitive pharmacy environment.</p>
<p>The Pharmacy Location Rules were introduced in the <a href="https://www.aph.gov.au/DocumentStore.ashx?id=523bbb1a-7e5f-485d-a8d5-d80b94a2c6d8&subId=561469">first Community Pharmacy Agreement</a> to help larger pharmacies generate efficiencies and profit through scale. The rules sweetened accompanying restrictions on PBS remuneration from the government. They have been included in each subsequent Community Pharmacy Agreement.</p>
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Read more:
<a href="https://theconversation.com/relaxing-pharmacy-ownership-rules-could-result-in-more-chemist-chains-and-poorer-care-122628">Relaxing pharmacy ownership rules could result in more chemist chains and poorer care</a>
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<p>The Pharmacy Location Rules were meant to expire in 2015 after the government initiated Competition Policy Review <a href="https://treasury.gov.au/publication/p2015-cpr-final-report">recommended</a> they “should be removed in the long term interests of consumers”. Instead, the guild <a href="https://www.theguardian.com/australia-news/2015/may/27/pharmacy-guild-shelves-protest-plans-after-compromise-deal-with-government">pulled back on a threat</a> made to the government to launch a major campaign on another policy initiative, in exchange for delaying the removal of the location rules for five years. </p>
<p>Upon further lobbying, the Pharmacy Location Rules sunset clause <a href="https://www.pbs.gov.au/general/sixth-cpa-pages/cpsf-files/cpsf-progress-of-commitments-compact-between-the-guild-and-health.docx">was removed</a> after the guild formed a Pharmacy Compact with the government in 2017. </p>
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<h2>Pharmacy policies that benefit consumers</h2>
<p>Some government policy change has aligned guild and patient interests.</p>
<p>Community pharmacists are increasingly providing services traditionally delivered by GPs. Pharmacists can now administer flu and COVID vaccines, and state trials allowing pharmacists to dispense oral contraception and antibiotics without a prescription are gaining favour.</p>
<p>This push towards greater scope of practice is embedded in the current and prior Community Pharmacy Agreements. But it threatens GP revenues.</p>
<p>The Australian Medical Association, the peak body for doctors, recently took a swing at the guild. It <a href="https://www.aph.gov.au/DocumentStore.ashx?id=cecc2818-fb71-4e9e-b2df-203e8c7e4e27&subId=736754">outlined ways</a> to improve pharmacy competition in a government submission, which included removing Pharmacy Location Rules and getting pharmacies to compete on medicine prices through discounting. </p>
<h2>What does this all mean for patients?</h2>
<p>The government has assured the guild that the $1.2 billion savings from allowing patients to fill two months’ supply of medicines will be invested directly back into pharmacies.</p>
<p>Savings will be used to <a href="https://www.health.gov.au/sites/default/files/2023-04/summary-of-strengthening-medicare-policies.pdf">further expand</a> the scope of practice for pharmacists, potentially informed by a National Scope of Practice Review to start in 2023.</p>
<p>Despite this assurance, the guild will fight. It has <a href="https://www.guild.org.au/news-events/news/2023/8-in-10-australians-reject-federal-budget-proposal-due-to-medicine-shortages">already canvassed</a> 2,500 “voters” across Australia on the budget proposal. In addition to reduced dispensing fee revenue, having patients with chronic diseases reduce their pharmacy visits by half means the opportunity to sell other products sitting on shelves is also halved.</p>
<p>Substantial health reform is on the horizon, but it won’t be painless. Policy change can upset embedded business models. It can impact livelihoods if providers don’t respond to their new regulatory environment. In the coming whirlwind of power struggles, wouldn’t it be nice if the government and providers worked together to put the patient first?</p>
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Read more:
<a href="https://theconversation.com/should-pharmacists-be-able-to-prescribe-common-medicines-like-antibiotics-for-utis-we-asked-5-experts-195277">Should pharmacists be able to prescribe common medicines like antibiotics for UTIs? We asked 5 experts</a>
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<img src="https://counter.theconversation.com/content/204028/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Henry Cutler does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Pharmacy Guild head wept at the thought of pharmacies losing income from a change that allows people with chronic diseases to halve their prescription costs. What’s going on?Henry Cutler, Professor and Director, Macquarie University Centre for the Health Economy, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1274972019-11-26T03:06:49Z2019-11-26T03:06:49ZThe evidence shows pharmacist prescribing is nothing to fear<figure><img src="https://images.theconversation.com/files/303618/original/file-20191126-84221-z63jla.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It can be more convenient getting a script from a pharmacist rather than visiting your GP.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/female-pharmacist-showing-medicine-male-customer-1341345770?src=bbb2e892-198b-43ab-91a7-6c159d3afa68-1-11">Jacob Lund/Shutterstock</a></span></figcaption></figure><p>Prominent GP and former member of parliament Kerryn Phelps has entered the turf war between doctors and pharmacists over who gets to prescribe. </p>
<p>Pharmacy groups have long called for changes to allow pharmacists to prescribe specified medications, such as the oral contraceptive pill and antibiotics for urinary tract infections. </p>
<p>But <a href="https://www.theaustralian.com.au/news/doctors-oppose-pharmacy-medical-consultations/news-story/4da72c5f4cd915e19fa0360a3a16a35a">Phelps argues</a> allowing pharmacists to prescribe will lead to perverse incentives – where pharmacists prescribe inappropriately – because they have a financial interest in the sale of medicines.</p>
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<p>Phelps has a point. Studies in countries where <em>doctors</em> have dispensing roles have found evidence of financial profits <a href="https://www.ncbi.nlm.nih.gov/pubmed/21729918">influencing</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/12917273">prescribing</a> behaviour. </p>
<p>A <a href="https://www.ncbi.nlm.nih.gov/pubmed/25393362">Swiss study</a>, for instance, found physician dispensing leads to a 34% increase in drug costs per patient, as doctors overprescribe and prescribe more expensive medications. </p>
<p>An <a href="https://eprints.soton.ac.uk/184777/3/ENPIPfullreport.pdf">evaluation</a> of <em>pharmacist</em> prescribing in the United Kingdom found it was safe, clinically appropriate, and was generally viewed positively by patients. </p>
<p>Similarly, two Canadian studies of pharmacist prescribing for <a href="https://www.ncbi.nlm.nih.gov/pubmed/31080530">urinary tract infections</a> and patients at risk of <a href="https://www.ncbi.nlm.nih.gov/pubmed/26063762">heart problems</a> found pharmacist prescribing led to better clinical outcomes. The researchers also found it was safe, cost effective, and associated with a high level of patient satisfaction. </p>
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Read more:
<a href="https://theconversation.com/over-the-counter-contraceptive-pill-could-save-the-health-system-96-million-a-year-116826">Over-the-counter contraceptive pill could save the health system $96 million a year</a>
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<p>Extending the scope of practice for pharmacists has the potential to lower costs to the health system because of fewer GP visits, be more convenient for consumers, and free up busy general practitioners to spend time on high-value care. </p>
<p>So what’s behind the concerns about pharmacist prescribing? And what does the research evidence say about them? Let’s look at three economic concepts that help us understand the benefits and risks of pharmacist prescribing. </p>
<h2>1. Supplier-induced demand</h2>
<p>Supplier-induced demand arises from information asymmetry – when the consumer is reliant on information from the supplier in order to make a decision. </p>
<p>In health care, supplier-induced demand occurs when a health professional shifts the demand that a consumer has for a drug or medical service beyond what they would demand if the consumer had perfect information. </p>
<p>What Phelps is suggesting is that a pharmacist may manipulate a consumer into purchasing an unnecessary drug. </p>
<p>When there is no information asymmetry, supplier-induced demand disappears. Paracetamol, for instance, is unlikely to be subject to supplier-induced demand despite direct sale from pharmacists because consumers have experience of using the product regularly and understand its effects.</p>
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<img alt="" src="https://images.theconversation.com/files/303622/original/file-20191126-84262-1fku918.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/303622/original/file-20191126-84262-1fku918.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=465&fit=crop&dpr=1 600w, https://images.theconversation.com/files/303622/original/file-20191126-84262-1fku918.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=465&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/303622/original/file-20191126-84262-1fku918.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=465&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/303622/original/file-20191126-84262-1fku918.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=585&fit=crop&dpr=1 754w, https://images.theconversation.com/files/303622/original/file-20191126-84262-1fku918.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=585&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/303622/original/file-20191126-84262-1fku918.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=585&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Pharmacists can’t really shift demand for common drugs like paracetamol and ibuprofen.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/boxes-prescription-painkillers-ibuprofen-paracetamol-on-390373792?src=88820570-7efe-463a-a231-5339dd60152b-1-30">Mr Doomits/Shutterstock</a></span>
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<p>There is no reported evidence of inappropriate prescribing by pharmacists in any countries that have introduced regulated, controlled models of pharmacist prescribing. </p>
<h2>2. Product bundling</h2>
<p>The Royal Australian College of General Practitioners (RACGP) has argued that if pharmacists prescribe oral contraceptives, patients would miss valuable services they would have received during the consultation with the GP. RACGP Queensland Chair Dr Bruce Willett told <a href="https://www1.racgp.org.au/newsgp/racgp/racgp-opposes-push-to-expand-pharmacist-scope-in-q">newsGP</a>:</p>
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<p>Limited repeats on medications such as oral contraceptives and cardiovascular disease medicines ensure patients can continue to be monitored by their GP while receiving treatments and medications, ensuring the right medication is prescribed at the right time.</p>
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<p>This reflects the economic concept of product bundling — where several products or services are sold in a single package. </p>
<p>The classic example is the bundling of newspapers with classified ads. These ads subsidised the newspaper’s journalism. But when online classifieds for cars and jobs began to compete with newspaper classifieds, newspapers lost the revenue that subsidised reporting and journalists lost their jobs. </p>
<p>Pharmacist prescribing could result in similar debundling. In this scenario, the pharmacist’s expanded role may result in prescribing being decoupled from the product bundle that is a GP consultation. Healthy women may not see the value of a GP consultation if they can obtain a prescription for oral contraceptives from their pharmacist with no consultation fee. </p>
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Read more:
<a href="https://theconversation.com/leave-pill-prescribing-to-gps-not-pharmacists-for-the-sake-of-womens-health-118120">Leave pill prescribing to GPs, not pharmacists, for the sake of women's health</a>
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<h2>3. Externality</h2>
<p>Some medicines have an impact on not only the person taking the medicine but society more broadly. This is what economists call an externality – a cost or benefit that is borne by an individual who did not choose to take on that cost or benefit. </p>
<p>Antibiotic resistance due to overuse, for instance, is estimated to have a global burden of <a href="https://www.safetyandquality.gov.au/sites/default/files/2019-05/aura-2017-second-australian-report-on-antimicrobial-use-and-resistance-in-human-health.pdf">A$140 trillion</a>. </p>
<p>The social cost of opiod addiction is another example. In the United States alone this cost was estimated to be over <a href="https://www.soa.org/resources/announcements/press-releases/2019/opioid-epidemic-cost-631-billion/?homepagecard=">US$600 billion</a> between 2015 and 2018. </p>
<p>When codeine was rescheduled as a prescription-only drug in Australia, there was a <a href="https://onlinelibrary.wiley.com/doi/10.1111/add.14798">50% reduction</a> in sales and a significant reduction in codeine poisonings. </p>
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Read more:
<a href="https://theconversation.com/heres-what-happened-when-codeine-was-made-prescription-only-no-the-sky-didnt-fall-in-124169">Here's what happened when codeine was made prescription only. No, the sky didn't fall in</a>
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<p>Conversely, a United Kingdom study of when antibiotic eye drops were rescheduled to be available over-the-counter <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/ijpp.18.05.00046.x">found</a> a doubling of sales. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/303623/original/file-20191126-84227-1ige9sv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/303623/original/file-20191126-84227-1ige9sv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/303623/original/file-20191126-84227-1ige9sv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/303623/original/file-20191126-84227-1ige9sv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/303623/original/file-20191126-84227-1ige9sv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/303623/original/file-20191126-84227-1ige9sv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/303623/original/file-20191126-84227-1ige9sv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Making medicines such as antibiotic eye drops easier to access can increase their use.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1466552123?src=81f20ae1-865c-4720-b6c1-aa8c637df8c6-1-33&size=huge_jpg">Jelena Stanojkovic/Shutterstock</a></span>
</figcaption>
</figure>
<p>Any increase in pharmacists’ scope of practice needs to be introduced with caution, with clear protocols and limited prescribing rights. </p>
<p>It also requires consideration of potential problems arising from increased availability, and robust monitoring and evaluation of the appropriateness and volume of prescriptions. </p>
<p>Neither side of the doctor-pharmacist turf war is showing signs of giving up. Rather than sweeping statements about conflicts of interest, we need an evidence-based framework to determine where it’s appropriate to extend pharmacists’ scope of practice.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-rivalries-between-doctors-and-pharmacists-turned-into-the-turf-war-we-see-today-122534">How rivalries between doctors and pharmacists turned into the 'turf war' we see today</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/127497/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Greg Merlo does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Prominent GP and former MP Kerryn Phelps has weighed into the doctor-pharmacist turf war, saying pharmacists shouldn’t prescribe because of their financial interests. But the evidence says otherwise.Greg Merlo, Postdoctoral Research Fellow, Primary Care Clinical Unit, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/687442016-11-17T03:25:04Z2016-11-17T03:25:04ZDiscount chemists are cheapening the quality of pharmacy along with the price<p>Every day, more discount pharmacy stores and chains are opening and assaulting health-care consumers with the “we are cheaper” message. But is price the best way to achieve positive health-care outcomes?</p>
<p>Community pharmacists are the only Australian health-care professionals to practise in a retail environment. When a patient “buys” a medication, it is easy to see how they can think they are purchasing a commodity. This perception is further fuelled by the retail and price-promotion focus by many (if not most) pharmacies.</p>
<p>Multiple times each week, I receive a pharmacy sale catalogue in my mailbox. Yes, it has the vitamins and complementary medicines, the perfumes and general retail lines like soaps and so on, but it also contains an array of medicines that are promoted as cheaply priced.</p>
<p>There’s a tension between the three major players in this space: consumers, pharmacy owners, and the health system.</p>
<h2>Consumers</h2>
<p>From a consumer perspective, anything that reduces the cost of an item is good. Cost of living is increasing, and everyone is looking for the next bargain. Price can be a huge motivator in driving purchasing behaviour and just about every retail outlet knows this and uses it to attract customers.</p>
<p>Many discount chains have large amounts of signage dedicated to giving the perception they are the cheapest, and if not, they will beat any competitor. This can attract customers for specific products they are seeking – usually products for a specific need, or high use items.</p>
<h2>Pharmacy owners</h2>
<p>Pharmacy owners are in business, and they need to make a profit or their business will fail and close. The profit they extract from each sale provides all the business costs (rent, electricity, staff, wholesale cost of products) and also a return for the owner. </p>
<p>Therefore, the owner will try to maximise profit at every opportunity. This can be achieved by reducing costs or increasing selling prices of goods. This is true for any pharmacy owner, not just discounters. However, discount pharmacies generate the perception they are cheaper, so something has to give.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/145923/original/image-20161115-15935-jiemal.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/145923/original/image-20161115-15935-jiemal.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/145923/original/image-20161115-15935-jiemal.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=521&fit=crop&dpr=1 600w, https://images.theconversation.com/files/145923/original/image-20161115-15935-jiemal.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=521&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/145923/original/image-20161115-15935-jiemal.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=521&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/145923/original/image-20161115-15935-jiemal.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=655&fit=crop&dpr=1 754w, https://images.theconversation.com/files/145923/original/image-20161115-15935-jiemal.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=655&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/145923/original/image-20161115-15935-jiemal.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=655&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Medicines shouldn’t be a commodity.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/fran001/15670055963/">Francisco Anzola/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Some of the things targeted for cost reduction by pharmacies can be:</p>
<ul>
<li><p><strong>Staff</strong>: pharmacists cost more per hour than pharmacy assistants, so minimising pharmacists and using pharmacy assistants can increase profits. Getting pharmacy assistants to do some of the tasks usually left up to pharmacists, such as providing patient information and answering questions, can also cut costs.</p></li>
<li><p><strong>“Non-billable” time</strong>: every time an employee is talking with a customer, that time has a cost (wages), but no direct return. If a product is sold, the hope is that the profit generated will reimburse the pharmacy for the time spent generating that sale. To address this, pharmacies can reduce the need for expensive staff to be involved in every purchase. Information is usually given with prescription and over-the-counter medicines. While private questions and information would be ideally shared in a private consulting room, this increases time per transaction. Whereas using a predominantly open segregated counter can reduce the questions asked and information sought – again reducing time.</p></li>
<li><p><strong>Low-priced common items</strong>: consumers do not remember the price of every item, but they know the prices of things they buy commonly. Many discount pharmacies will determine these products and have their “top list” of 100, 150 or 200 items. These will be regarded as “loss leaders” and will be very competitively priced, whereas other products will have higher margins to subsidise the loss leader price reductions. If a consumer does happen to notice this, a price reduction on a single sale does not jeopardise the profit on the other sales made off that product.</p></li>
</ul>
<h2>Health system perspective</h2>
<p>The health system aims to provide a high level of care for the most people possible at an affordable cost. Pharmacy owners will say the system doesn’t pay them enough to perform a variety of tasks. Consumers will say they pay too much out of pocket and the system should pay more. The system tries to maintain a balance between the two.</p>
<p>Discount pharmacies are driving down prices for a variety of non-prescription medicines and the government de-listed some medications it used to subsidise, saying their cost was the same or lower without a prescription. This makes price a factor and further leads to medicines having a perceived value in the consumer’s mind.</p>
<p>The health system deals with more than 200,000 hospital admissions each year (<a href="https://safetyandquality.gov.au/wp-content/uploads/2013/08/Literature-Review-Medication-Safety-in-Australia-2013.pdf">costing over A$1 billion</a>), and <a href="https://safetyandquality.gov.au/wp-content/uploads/2013/08/Literature-Review-Medication-Safety-in-Australia-2013.pdf">at least half are preventable</a>. </p>
<p>Medicines are the most cost effective and easiest to administer health intervention. Therefore the health system wants to ensure the Australian policy on quality use of medicines is followed to maximise the benefits for the patient and the budget, and minimise the harms.</p>
<h2>Race to the bottom in price and quality</h2>
<p>Our pharmacy system is built around a retail entity where the income is derived from selling a product, not advice. Today’s pharmacy retail model is becoming a “race to the bottom” on price. </p>
<p>Pharmacies that give advice when selling a product, and have appropriate staffing levels to maximise health-care outcomes, are becoming rare as consumers follow the price to the bottom. </p>
<p>The problem with such medication consumerism is it increases the risk of medicines-related harm. Consumers should always ask questions about their medicines regardless of the type of pharmacy where they buy them. If your pharmacist doesn’t answer your questions to your satisfaction – go to a pharmacy that will.</p><img src="https://counter.theconversation.com/content/68744/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Greg Kyle is a member of the Pharmaceutical Society of Australia. </span></em></p>Every day, more discount pharmacy stores and chains are opening and assaulting health-care consumers with the “we are cheaper” message.Greg Kyle, Professor of Pharmacy, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/416822015-05-13T20:14:03Z2015-05-13T20:14:03ZBudget entrée disappoints but PBS reform still on the menu<figure><img src="https://images.theconversation.com/files/81352/original/image-20150512-22583-kb5wjh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The leaked measures would have benefited consumers and taxpayers, with small imposition on the lucrative bottom lines of pharmacists and the pharmaceutical industry.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/nvinacco/2656558985/">NVinacco/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span></figcaption></figure><p>A significant element of this year’s budget was <a href="http://www.afr.com/news/policy/budget/government-targets-subsidies-medicine-as-part-of-7b-budget-savings-20150426-1mtqrc">supposed to be major reforms to the Pharmaceutical Benefits Scheme</a> (PBS) with projected savings of more than $3 billion over the next four years. But even though <a href="http://www.abc.net.au/radio/programitem/pg5L7KMoZ6?play=true">health minister Sussan Ley foreshadowed the changes</a>, the budget contained few reforms. </p>
<p>Instead it showed savings of just $252.2 million over five years from adjusting the price of a small number of PBS-listed drugs. But <a href="http://www.health.gov.au/internet/budget/publishing.nsf/Content/2015-2016_Health_PBS_sup1/$File/2015-16_Health_PBS_0.0_Complete.pdf">buried deep on page 53 of the budget papers</a> is a statement that: </p>
<blockquote>
<p>From 1 July 2015, the Government expects to introduce a balanced range of measures to support the longer-term access to, and sustainability of, the PBS. </p>
</blockquote>
<p>It would appear that the announced cuts are just an entree. We must now wait for the main course. </p>
<h2>Budgetary pressures</h2>
<p>As <a href="http://www.health.gov.au/internet/budget/publishing.nsf/Content/2015-2016_Health_PBS_sup1/$File/2015-16_Health_PBS_0.0_Complete.pdf">the budget papers make clear</a>, pharmaceutical expenditure is rising due to the listing of new medications. A key driver has been the emergence of a range of high-cost drugs, such as a treatment for malignant melanoma (trametinib) which costs over $131,000 per course of treatment. </p>
<p>This year’s budget includes funding for seven such drugs, at a projected cost of $1.6 billion over the next four years. But it’s important to note that, at its most recent meeting, the <a href="http://www.pbs.gov.au/info/industry/listing/elements/pbac-meetings/pbac-outcomes/2015-03">Pharmaceutical Benefits Advisory Committee (PBAC)</a>, the expert body that advises government on which drugs to add to the PBS, recommended adding a further $2.5 billion worth of new drugs. </p>
<p>The pipeline of new drugs places real and ongoing pressure on the government to find savings, particularly as the budget papers indicate the projected rate of increase in PBS expenditure will rise significantly over the next few years. Fortunately, when it comes to the PBS, savings are relatively easy to find.</p>
<p>Proposals floated by the government in the media over recent weeks included:</p>
<ul>
<li><a href="http://www.abc.net.au/radio/programitem/pg5L7KMoZ6?play=true">removing many medications from the PBS</a> that could be bought over the counter, such as aspirin and paracetemol </li>
<li><a href="http://www.abc.net.au/pm/content/2015/s4231687.htm">accelerating reductions in the price</a> of generic medicines </li>
<li>closing a <a href="http://www.news.com.au/lifestyle/health/drug-company-trick-of-combining-two-pills-into-one-and-charging-patients-twice-as-much-to-end/story-fneuzlbd-1227337682928">loophole that allows pharmaceutical companies</a> to charge much more for combination drugs, which are simply when two drugs are combined into a single tablet </li>
<li>an <a href="http://www.theaustralian.com.au/subscribe/news/1/index.html?sourceCode=TAWEB_WRE170_a&mode=premium&dest=http://www.theaustralian.com.au/national-affairs/health/budget-2015-drug-firms-prepare-for-war/story-fn59nokw-1227339810429&memtype=anonymous">across-the-board 5% cut</a> to the prices of medications that are still under patent, but have been listed on the PBS. </li>
</ul>
<p>Reportedly, there were also plans to introduce a modicum of competition into the pharmacy sector by allowing pharmacists to offer a discount of up to $1 on their dispensing fees. </p>
<p>The health minister has flagged her willingness to consider a broad range of reforms like these as part of negotiations for the next agreement between the Commonwealth and the retail pharmacy sector. This will cover payments made by government for dispensing drugs. That might explain why the budget papers say new measures will come into force on July 1 2015. The current agreement is due to expire on June 30.</p>
<h2>Good ideas</h2>
<p>The suggested reforms were all good ideas. Take generic medicines, for example. It has long been known that <a href="https://www.mja.com.au/journal/2010/193/3/expiry-patent-protection-statins-effects-pharmaceutical-expenditure-australia-0">Australia has being paying too much</a> for many common generic drugs. While generic drug prices have come down in recent years, we are still paying many times more for medicines such as the antipsychotic Olanzapine, which remains 15 times more expensive than in England. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/81367/original/image-20150512-22571-606my8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/81367/original/image-20150512-22571-606my8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=522&fit=crop&dpr=1 600w, https://images.theconversation.com/files/81367/original/image-20150512-22571-606my8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=522&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/81367/original/image-20150512-22571-606my8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=522&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/81367/original/image-20150512-22571-606my8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=656&fit=crop&dpr=1 754w, https://images.theconversation.com/files/81367/original/image-20150512-22571-606my8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=656&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/81367/original/image-20150512-22571-606my8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=656&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Currently, the government sets generic prices through what’s known as <a href="http://www.pbs.gov.au/info/industry/pricing/eapd">Expanded and Accelerated Price Disclosure</a>. It sets future prices by collecting information on the wholesale prices pharmacies around Australia pay for these medications, which are often at substantial discounts offered by drug manufacturers. </p>
<p>The proposed plan was to accelerate reductions in the price of these medications by excluding the original brand of drug (which is often discounted less than generic brands of the same drug) when calculating average cost. </p>
<p>Similarly, the government could make significant savings by tackling one of the great PBS pricing anomalies concerning <a href="https://www.mja.com.au/journal/2014/200/9/evaluating-costs-and-benefits-using-combination-therapies">combination drugs</a>. Price reductions for these drugs have been much slower than for other types of generic drugs, so they are often much more expensive than individual component drugs. Take the <a href="http://pbs.gov.au/medicine/item/10169F-2275R-4179Y-5436D-8358X-9317J-9354H">stroke prevention medication clopidogrel</a>, which costs around $15 per script on its own, but <a href="http://pbs.gov.au/medicine/item/9296G">$40 when combined with aspirin</a>.</p>
<p>While the 2015 budget papers did indicate an adjustment to the price of one combination (Ezetimibe with simvastatin), closing this pricing loophole across all combination therapies should net the government savings of more than $800 million over the next four years. </p>
<p>Probably the most controversial of the mooted savings measures was an across-the-board cut to subsidies for listed medications after a period of time. Reducing the subsidy on PBS drugs over time, mimics the way the prices for innovative products, such as new features on mobile phones, decline over time.</p>
<p>While this measure would clearly impact the profits of some pharmaceutical manufacturers, it should be seen in the context of many uncertainties these businesses face. The recent decline in the Australian dollar, for instance, creates much greater fluctuations in revenues for these companies than this proposed cut would have. </p>
<h2>Like laws and sausages</h2>
<p>The other group that would have been significantly impacted by the reforms are pharmacy owners as the revenue they receive from discounts on generic drugs would have fallen. But these discounts have always been a bonus on top of the $3 billion a year the retail pharmacy sector receives through the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/fifth-community-pharmacy-agreement">agreement with the Commonwealth government</a> negotiated by the Pharmacy Guild of Australia.</p>
<p>In the past, the guild has run campaigns arguing such changes would put some pharmacies under threat, one of which it claims <a href="http://www.guild.org.au/news-page/2013/09/19/media-release---over-1-000-000-signatures-for-community-pharmacy">attracted over one million signatures</a>. </p>
<p>What was different about this set of proposed reforms was that the government also floated the idea of allowing pharmacies to discount their dispensing charges. This would have given consumers a direct stake in the reforms because they would have saved money when having prescriptions filled. </p>
<p>But even though the next Community Pharmacy Agreement is imminent and the budget papers hint at PBS reform, we have no way of knowing whether anything will actually change. Reforms are negotiated behind closed doors directly with the Pharmacy Guild and the drug industry lobby group Medicines Australia. </p>
<p>Negotiations have always been far from transparent. It’s never clear what gets traded off by whom and why. Or what relative weight is given to evidence versus stakeholder clout in shaping future reforms. </p>
<p>The limitations of past negotiations were highlighted in a recent National Audit Office report into the last Community Pharmacy Agreement, which involved the framework to allocate $15 billion of taypayer funds. <a href="http://www.anao.gov.au/%7E/media/Files/Audit%20Reports/2014%202015/Report%2025/AuditReport_2014-2015_25B.pdf">The report noted that</a>, among other things, the health department had failed to “keep a record of its meetings with the Pharmacy Guild”. </p>
<p>When it comes to PBS reform, this government appears to have taken <a href="http://www.brainyquote.com/quotes/quotes/o/ottovonbis161318.html#2mO3j3AOKLBBGiWZ.99">the advice of Otto von Bismarck</a>:</p>
<blockquote>
<p>Laws are like sausages, it is better not to see them being made.</p>
</blockquote>
<p>But with so many savings options on the menu, now is not the time to go on a reform diet.</p><img src="https://counter.theconversation.com/content/41682/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Philip Clarke does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Despite numerous leaks about impending changes to medicines policy, the budget showed savings of just $252.2 million over five years from adjusting the price of a small number of PBS-listed drugs.Philip Clarke, Professor of Health Economics, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/387892015-04-07T04:37:35Z2015-04-07T04:37:35ZExplainer: what is the Community Pharmacy Agreement?<figure><img src="https://images.theconversation.com/files/77082/original/image-20150406-26512-nagmgn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Patients pay a contribution towards the cost of their medication to the pharmacist who then claims the difference between what they paid and the patient contribution from the government.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/gustavominas/4895616255">Gustavo Gomes/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>The <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/fifth-community-pharmacy-agreement">Community Pharmacy Agreement</a> is a five-year agreement (<a href="http://5cpa.com.au/">now in its fifth cycle</a>) that governs how pharmacies supply medicines listed on the <a href="http://www.pbs.gov.au/pbs/home">Pharmaceutical Benefits Scheme</a> (PBS). While the average Australian <a href="http://www.guild.org.au/docs/default-source/public-documents/issues-and-resources/Fact-Sheets/the-fifth-community-pharmacy-nbsp-agreement.pdf?sfvrsn=0">makes more than 14 visits</a> to a community pharmacy every year, not many know about how this agreement impacts pharmacy in Australia.</p>
<p>Pharmacies buy medication from wholesalers, sell them to people who bring in prescriptions and <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/fifth-community-pharmacy-agreement">are reimbursed</a> by the government for drugs listed on the PBS. They’re also paid for the professional advice they provide when dispensing those medicines.</p>
<p>Patients pay a contribution towards the cost of their medication to the pharmacist, who then claims from the government the difference between what they paid the wholesaler and the patient contribution. In the financial year ending June 30 2014, the government spent $9.1 billion on PBS-listed drugs. Exactly what this money went to was governed by the Community Pharmacy Agreement.</p>
<h2>Getting approval</h2>
<p>The agreement is formed between the Pharmaceutical Guild of Australia (PGA) and the Commonwealth government because of a key clause in the <a href="http://www.comlaw.gov.au/Details/C2015C00081">National Health Act 1953</a>. This says any agreement relating to how the Commonwealth remunerates items on the PBS needs to be made with the PGA or another pharmacists’ organisation that represents the majority of “approved pharmacists”. </p>
<p>Approval requires pharmacists to apply to the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pbs-general-pharmacy-acpa-index.htm-copy2">Australian Community Pharmacy Authority</a> (ACPA), an independent statutory authority that considers applications to supply PBS medicines under Section 90 of the Act. As part of assessing applications, the ACPA has to consider the location of the proposed pharmacy because we need pharmacies to form a distribution network so everyone in the country has access to PBS-listed drugs. </p>
<p>In Australia, you can only own a pharmacy if you are a qualified pharmacist. So the people representing the approved “Section 90” pharmacies are pharmacist-owners, and the Pharmaceutical Guild is their professional organisation.</p>
<h2>A brief history</h2>
<p>The first <a href="http://www.guild.org.au/the-guild/community-pharmacy-agreement">Community Pharmacy Agreement</a> (CPA) began in 1991 and its focus was on optimising the distribution of pharmacy services around the country. At the time, there were concerns that more pharmacies were located in metropolitan areas while regional and rural Australia went without. The agreement introduced a new remuneration framework for pharmacies supplying PBS medicines and created incentives for pharmacies in rural and remote areas. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/77083/original/image-20150406-26502-ysv5gh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/77083/original/image-20150406-26502-ysv5gh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/77083/original/image-20150406-26502-ysv5gh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/77083/original/image-20150406-26502-ysv5gh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/77083/original/image-20150406-26502-ysv5gh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/77083/original/image-20150406-26502-ysv5gh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/77083/original/image-20150406-26502-ysv5gh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In Australia, you can only own a pharmacy if you are a qualified pharmacist.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/renaissancechambara/4487061237">Ged Carroll/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>The CPA was <a href="http://www.comlaw.gov.au/Details/C2004B00706/2e1056bd-e75d-4653-9a1b-d629c8fb221e">also a response</a> to concerns in government and the pharmacy profession about Australia’s large pharmacy-to-population ratio (much higher than other Western countries) and the lack of consistency in various financial drivers across the profession, including for mark-ups and fees for dispensing PBS medicines. </p>
<p>Under the first CPA, the number of pharmacies in Australia fell from 5,500 to 4,950 by the end of 1995. This included voluntary closures of over 600 pharmacies and more than 60 mergers, and cost the government more than $50 million.</p>
<p><a href="http://www.comlaw.gov.au/Details/C2004B00706/2e1056bd-e75d-4653-9a1b-d629c8fb221e">Each subsequent agreement</a> has helped maintain the principle of equal distribution of pharmacies across the country through controls placed on the profession via the location rule, which says a pharmacy may not open within 1.5 kilometres of an existing one.</p>
<p>The <a href="http://5cpa.com.au/">fifth Community Pharmacy Agreement</a>, which commenced on July 1 2010, also contains remuneration ($663 million, or less than 5% of the total CPA budget) for clinical services that enhance patient medication management. These include one-on-one <a href="https://theconversation.com/medicine-reviews-save-lives-and-money-so-why-are-they-capped-23315">medication reviews</a>, which can take between 20 and 30 minutes in-store, or up to an hour in the patient’s home. </p>
<p>The current CPA totals $15.4 billion, with the bulk of the funding ($13.8 billion) allocated directly to individual pharmacies for PBS-related services.</p>
<h2>A final part of the puzzle</h2>
<p>Another critical part of the CPA is the Community Services Obligation (CSO), which is an arrangement between the government and pharmaceutical wholesalers. The core of the CPA arrangement is access to PBS medicines and wholesalers who supply the pharmacies are pivotal players in the supply chain. </p>
<p>The CPA provides direct financial support ($950 million) to certain pharmaceutical wholesalers for any additional cost they may incur in providing the full range of PBS medicines. This ensures the full range is available regardless of pharmacy location and relative cost of supply. It also helps ensure that low-volume PBS medicines, which are often very high-cost drugs, are delivered to community pharmacies anywhere in Australia within 24 hours. </p>
<p>Since its inception 25 years ago, the intent of the Community Pharmacy Agreement has been to ensure all Australians have access to PBS-listed medications, no matter where they live. Australia’s network of around 5,500 community pharmacies have played a pivotal role in realising this goal.</p><img src="https://counter.theconversation.com/content/38789/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lisa Nissen received funding previously from the 3rd and 4th Community Pharmacy Agreement Research and Development Grant Programs. Lisa currently holds an Office of Learning and Teaching (OLT) Research Grant. She is affiliated with the Pharmaceutical Society of Australia (Qld) Branch where she is a branch committee member.</span></em></p><p class="fine-print"><em><span>Judith Singleton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Australians make an average of 14 visits to the pharmacy for medicines and advice every year but most don’t know about the agreement that governs how we buy government-subsidised medicines from them.Lisa Nissen, Professor; Head, School of Clinical Sciences, Queensland University of TechnologyJudith Singleton, Lecturer, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/396422015-04-06T20:10:45Z2015-04-06T20:10:45ZThe right prescription: pharmacy sector in dire need of reform<figure><img src="https://images.theconversation.com/files/77084/original/image-20150406-26488-13vmtxq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ownership and location rules ensure that Australia's pharmacy sector is protected from competition. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/rabulist/5229061928">Anders/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>Among the most significant reforms proposed by recently released <a href="http://competitionpolicyreview.gov.au/">Harper Competition Policy Review</a> is the removal of regulatory restrictions that greatly limit competition in the community pharmacy sector. But implementing the recommendation will require politicians who are up for a real challenge. </p>
<p>Any changes to how the pharmacy sector works involves taking on what has been described as “<a href="http://www.smh.com.au/federal-politics/political-opinion/the-pharmacy-guild-the-most-powerful-lobby-group-youve-never-heard-of-20150401-1mckxl.html">the most powerful lobby group you’ve never heard of</a>.” The <a href="http://www.guild.org.au/">Pharmacy Guild of Australia</a>, which represents the interest of pharmacy owners, is widely perceived as one of the most influential lobby groups in Australia.</p>
<h2>Monoploy rents</h2>
<p>Australian pharmacies are currently protected from competition by two sets of government regulations that form part of what’s known as the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/fifth-community-pharmacy-agreement">Community Pharmacy Agreement</a>. Negotiated every five years between the Federal government and Pharmacy Guild of Australia, the agreement regulates most aspects of the pharmacy sector, from remuneration for supplying government-subsidised drugs to rules about the ownership and location of pharmacies. </p>
<p>The ownership rules disallow non-pharmacists from owning a pharmacy. So they effectively keep supermarkets and large international pharmacy chains, such as the UK’s Boots, from owning pharmacies in Australia. </p>
<p>The location rules were introduced as part of the first pharmacy agreement in the early 1990s. It prevents new pharmacies opening within a kilometre and a half of an existing pharmacy. </p>
<p>These ownership and location restrictions have effectively prevented new entrants into the sector and created what economists call <a href="http://en.wikipedia.org/wiki/Rent-seeking">monopoly rents</a> for existing pharmacy owners. Monopoly rents represent the benefits that an industry gains from politically-enforced regulations to restrict competition. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/77087/original/image-20150406-26507-1wt1nwa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/77087/original/image-20150406-26507-1wt1nwa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/77087/original/image-20150406-26507-1wt1nwa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/77087/original/image-20150406-26507-1wt1nwa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/77087/original/image-20150406-26507-1wt1nwa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/77087/original/image-20150406-26507-1wt1nwa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/77087/original/image-20150406-26507-1wt1nwa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">As well as the increase in amounts paid to pharmacies each time a drug is dispensed, government payments are now around 20% higher in real terms than in the early 1990s.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/orqwith/4378626741">quimby/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
</figcaption>
</figure>
<p>While reform of the pharmacy sector by removing these restrictions has been championed by commentators from as diverse political backgrounds as <a href="http://www.awu.net.au/opinions/no-room-left-pharmacy-guild%E2%80%99s-sweetheart-deals">Paul Howes</a> and <a href="http://www.theaustralian.com.au/opinion/columnists/drug-cartel-injects-cash-for-pharmacists/story-e6frg7bo-1227266932370">Janet Albrechtson</a>, none of Australia’s politicians from any of the major political parties have so far taken up the cause.</p>
<h2>Report after report</h2>
<p>The <a href="http://competitionpolicyreview.gov.au/final-report/">competition review recommendation</a> is unequivocal:</p>
<blockquote>
<p>the pharmacy ownership and location rules should be removed in the long-term interests of consumers.</p>
</blockquote>
<p>And it comes after a similar recommendation from the 2014 <a href="http://www.ncoa.gov.au/report/phase-one/part-b/7-4-the-pharmaceutical-benefits-scheme.html">National Commission of Audit report</a>, which advocated:</p>
<blockquote>
<p>opening up the pharmacy sector to competition, including through the deregulation of ownership and location rules.</p>
</blockquote>
<p>Then there’s the report from the Australian National Audit Office (<a href="http://www.anao.gov.au/Publications/Audit-Reports/2014-2015/Administration-of-the-Fifth-Community-Pharmacy-Agreement/Audit-summary">ANAO</a>), which conducted a performance audit of the administration of the fifth Community Pharmacy Agreement (ending June 2015). The ANAO found so many shortcomings in administration of the agreement by the Department of Health that it was:</p>
<blockquote>
<p>not well positioned to assess whether the Commonwealth is receiving value for money from the agreement overall.</p>
</blockquote>
<p>The ANAO report quantified the remuneration pharmacies have received from government since the early 1990s, when the first Community Pharmacy Agreement was put in place. The figure below shows payments pharmacies receive for dispensing and mark-ups (the amount of money added to the price of drugs, to cover overheads and profit) have tripled from around $750 million in 1991 to over $2 billion by 2013 – even after adjusting for inflation. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/77085/original/image-20150406-26479-chw5bq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/77085/original/image-20150406-26479-chw5bq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/77085/original/image-20150406-26479-chw5bq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=622&fit=crop&dpr=1 600w, https://images.theconversation.com/files/77085/original/image-20150406-26479-chw5bq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=622&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/77085/original/image-20150406-26479-chw5bq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=622&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/77085/original/image-20150406-26479-chw5bq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=782&fit=crop&dpr=1 754w, https://images.theconversation.com/files/77085/original/image-20150406-26479-chw5bq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=782&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/77085/original/image-20150406-26479-chw5bq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=782&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>This growth is due to much higher volumes of dispensing due to a combination of population increase, ageing, and expanded prescribing from newer classes of drugs, such statins. But as well as the increase in amounts paid to pharmacies each time a drug is dispensed, government payments are now around 20% higher in real terms than in the early 1990s, due largely to greater pharmacy remuneration from mark-ups.</p>
<p>And while total remuneration has substantially increased, restrictions on competition mean there are actually fewer pharmacy businesses in Australia than when the first community agreement was negotiated in the early 1990s. </p>
<h2>Who wants to be a millionaire?</h2>
<p>The ANAO report also provides a distribution breakdown of this remuneration across different types of pharmacies. As the graph below shows, around 18% of pharmacies receive more than $1 million in remuneration from dispensing drugs listed on the Pharmaceutical Benefits Scheme. A comparison of the 2012 and 2013 financial years indicates a further 140 pharmacies moved into this top-earning bracket. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/77086/original/image-20150406-26518-in44xt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/77086/original/image-20150406-26518-in44xt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/77086/original/image-20150406-26518-in44xt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=536&fit=crop&dpr=1 600w, https://images.theconversation.com/files/77086/original/image-20150406-26518-in44xt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=536&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/77086/original/image-20150406-26518-in44xt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=536&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/77086/original/image-20150406-26518-in44xt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=673&fit=crop&dpr=1 754w, https://images.theconversation.com/files/77086/original/image-20150406-26518-in44xt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=673&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/77086/original/image-20150406-26518-in44xt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=673&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>The high profitability of established pharmacies mean <a href="http://www.pharmacysales.com.au/forsale/vic">business sale prices</a> for inner city and suburban pharmacies can run into the millions. And this high purchase price locks out many pharmacy graduates from ever owning their own business. It also means new entrants are saddled with levels of debt that turn what should be profitable business into marginal ones.</p>
<p>All this creates what might be termed a cycle of rent-seeking: while the ownership and location rules protect existing owners, the next generation of pharmacy owners will have to buy their businesses at inflated prices. And this makes new owners seek ever more protection from competition to make their business profitable and, in some cases, viable.</p>
<p>This might also partly explain campaigns such as “<a href="http://www.guild.org.au/docs/default-source/public-documents/news-and-events/Community-Pharmacy-Under-Threat/media-release---pharmacy-jobs-services-to-go-after-shock-government-decision-(nsw).pdf?sfvrsn=0">Pharmacy Under Threat</a>”, which was run by the Pharmacy Guild of Australia. It was held in the middle of the last Federal election campaign against the relatively modest reforms proposed by the former government to accelerate reductions in price of generic drugs.The Guild claims that a petition distributed through a network of community pharmacies attracted <a href="http://www.guild.org.au/news-events/forefront/volume-4-number-40/pharmacy-under-threat-triumphs">1.2 million signatures</a>.</p>
<p>Of course, the lack of competition in the sector comes at a cost to the consumer, both in terms of the choice of where they can shop and in the prices that must be paid. As the ANAO report demonstrates, a packet of aspirin, which may cost as little as $3 in retail marketplace costs up to $12 when it is dispensed under the PBS. </p>
<p>Still, while the economic arguments for increased competition are strong, the politics of implementing community pharmacy reforms remain another matter. As one of history’s most astute political commentators <a href="https://www.goodreads.com/author/show/16201.Niccol_Machiavelli">Niccolò Machiavelli</a> once observed, there is:</p>
<blockquote>
<p>nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than a new system. For the initiator has the enmity of all who would profit by the preservation of the old institution and merely lukewarm defenders in those who gain by the new ones.</p>
</blockquote>
<p>It’s this challenge that faces any reform-minded politician wanting to introduce more competition into Australia’s pharmacy sector.</p><img src="https://counter.theconversation.com/content/39642/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Philip Clarke does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Despite calls for reform to make the pharmacy sector more competitive, governments are loath to take on the quietly-powerful Pharmacy Guild of Australia, the professional body for pharmacists.Philip Clarke, Professor of Health Economics, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/233152014-02-25T19:41:40Z2014-02-25T19:41:40ZMedicine reviews save lives and money, so why are they capped?<figure><img src="https://images.theconversation.com/files/42444/original/59tg4h4g-1393304556.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Pharmacy Guild recently announced that medication reviews will now be capped.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/gatiuss/5223834995/sizes/l/">Gatis Gribusts/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>Reviews by specially-trained pharmacists of the medication taken by elderly people have been funded by the federal government for over 15 years now. But a secret deal followed by a sudden announcement by the Pharmacy Guild means the service will now be limited.</p>
<p>In Australia, medicine-related reactions <a href="http://www.ncbi.nlm.nih.gov/pubmed/14660523">account for over a third</a> of unplanned hospital admissions in older people. Taking the wrong medicines together, taking too high or too low a dose, or taking certain medicines when your kidneys are not working well can lead to ineffective disease management, toxic reactions, and, in the worst case, preventable deaths. </p>
<p>Older residents in aged care are among the most vulnerable. In <a href="http://www.theage.com.au/comment/aged-care-drug-abuse-that-points-to-scandal-20140105-30bni.html">her column in The Age</a> early this year, former Howard government minister Amanda Vanstone described one such case where a new resident had been given a whole new regime of drugs (many of which treated conditions she didn’t have) until a relative asked questions about it. </p>
<p>A timely medication review by a consultant pharmacist could easily have resolved the situation. And up to a couple of weeks ago, Australia had an excellent program of just such reviews. </p>
<p>We were doing so well, in fact, that our medication management services were the <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2645146/">envy of the developed world</a>. But that all changed when these services were capped through a back-room deal struck between the Pharmacy Guild of Australia and the Department of Health.</p>
<h2>Medication review services</h2>
<p>For more than 15 years, specially-trained consultant pharmacists – either independent or based in a community pharmacy – have been funded by the federal government to provide medication management services in aged-care facilities. More recently, they’ve also provided the service in people’s homes. </p>
<p>The service was started as a response to high rates of inappropriate medication use in aged-care facilities, and <a href="http://www.racgp.org.au/afp/200604/200604quirke.pdf">research showing</a> medication reviews could positively impact patient care. <a href="http://circheartfailure.ahajournals.org/content/2/5/424.full">Medication reviews</a> also improve the quality of medicine use, and reduce hospital admissions and adverse medication events.</p>
<p>They save money for both the health-care system (fewer hospital admissions and drugs being subsidised) and people too. <a href="http://scielo.isciii.es/pdf/pharmacy/v4n3/en_revision.pdf">One US study</a> reported that 43% of residents of an aged-care facility spent less money every month on medicines after a medication review, with the average savings of US$30 per resident per month. </p>
<p>The review starts with a doctor referring a patient whose medication regime is then looked at by an accredited pharmacist. This pharmacist makes written recommendations to address issues such as duplicated drugs, interactions or adverse effects. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/42445/original/yxn355y8-1393304841.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/42445/original/yxn355y8-1393304841.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=339&fit=crop&dpr=1 600w, https://images.theconversation.com/files/42445/original/yxn355y8-1393304841.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=339&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/42445/original/yxn355y8-1393304841.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=339&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/42445/original/yxn355y8-1393304841.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=426&fit=crop&dpr=1 754w, https://images.theconversation.com/files/42445/original/yxn355y8-1393304841.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=426&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/42445/original/yxn355y8-1393304841.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=426&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A timely medication review by a consultant pharmacist can save lives and money.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/mtsofan/2060252723/sizes/o/">John/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
</figcaption>
</figure>
<p>Currently, a pharmacist is given A$200 to perform a medication review in a person’s home and A$100 dollars for a review in an aged-care facility. </p>
<p>As consultant pharmacists, we have seen firsthand what a difference this service can make. Sometimes, it’s just simple things like finding a patient taking the same medication with different brand names. But we’ve also encountered serious interactions and adverse effects that, if left unaddressed, were highly likely to lead to significant harm or worse. </p>
<p>A big part of the review process entails listening to patient concerns, educating them about their medicines and disease states, and hopefully improving medication adherence. The latter is especially important because it’s known to be a problem for people with long-term conditions, such as high blood pressure, diabetes, and respiratory disease.</p>
<h2>Restrictions to a valuable service</h2>
<p>Reflecting the value and high regard in which medication review services are held, demand has increased and the budget has started to run out. </p>
<p>The Government Pharmacy Agreement provides A$15.4 billion for five years to community pharmacies for dispensing and providing health services. Of this sum, A$122 million, just 0.8%, has been allocated for medication review services. </p>
<p>The outcome of the increasing demand was a surprise recent <a href="http://www.guild.org.au/docs/default-source/public-documents/news-and-events/media-releases/2014/mr_cpa-changes_12-feb2014.pdf?sfvrsn=2">announcement by the Pharmacy Guild</a> (not the government) that the number of medication reviews each pharmacist can undertake will now be capped to 20 a month. And there’s now a minimum two-year interval between reviews.</p>
<p>Contrary to what its name suggests, the Pharmacy Guild doesn’t represent the interests of the majority of pharmacists in Australia, of which there are more than 26,000. It speaks for its membership - less than 5,000 pharmacy owners – who derive little profit from medication review services. </p>
<p>In the <a href="http://www.guild.org.au/docs/default-source/public-documents/news-and-events/media-releases/2014/mr_cpa-changes_12-feb2014.pdf?sfvrsn=2">very same press release</a> that the medication management caps were broadcast, a brand new payment was announced; up to A$2,000 per community pharmacy for meeting two targets for electronic barcode scanning of prescriptions, which is routine practice in many community pharmacies already. </p>
<p>Accredited pharmacists and patient groups weren’t consulted before either arrangement was made, nor were other professional organisations. The deal was made exclusively between the government and an organisation representing the sole interests of pharmacist owners. </p>
<p>If the government is serious about providing medication management services that make a valuable contribution to the nation’s health, then the restriction on medicine reviews should be lifted. Otherwise, Australia’s standing as a shining light in the field of medicines management will rapidly fade and vulnerable members of our society will be left without timely access to a much-valued service.</p><img src="https://counter.theconversation.com/content/23315/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Juanita performed the first funded home medication review service in Australia as part of the Quality Use of Medicines in the Community trial over 15 years ago. At present, she performs 1-2 HMRs a month.</span></em></p><p class="fine-print"><em><span>Angus Thompson is an independent accredited Home Medicines Review (HMR) pharmacist who is not directly affected by the cap due to the small number of reviews done each month.</span></em></p>Reviews by specially-trained pharmacists of the medication taken by elderly people have been funded by the federal government for over 15 years now. But a secret deal followed by a sudden announcement…Juanita Breen (previously Westbury), Lecturer in Pharmacy Practice and Research Fellow, University of TasmaniaAngus Thompson, Lecturer in Therapeutics and Pharmacy Practice, University of TasmaniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/231872014-02-25T03:30:35Z2014-02-25T03:30:35ZShould pharmacists get $50 to give you a health check?<figure><img src="https://images.theconversation.com/files/42333/original/hp85n6rf-1393217103.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pharmacists' skills go well beyond dispensing drugs but a one-off check would do little to achieve integrated care.</span> <span class="attribution"><span class="source">Image from shutterstock.com</span></span></figcaption></figure><p>The Pharmacy Guild <a href="http://www.news.com.au/lifestyle/health/pharmacy-guild-to-be-fat-cops-checking-weight-and-peoples-health/story-fneuzlbd-1226820930087">has proposed</a> a scheme that would see the Commonwealth government pay pharmacists A$50 to provide one-off health checks. Pharmacists checks would assess patients’ <a href="https://theconversation.com/explainer-overweight-obese-bmi-what-does-it-all-mean-7011">body mass index</a>, blood pressure, blood glucose, cholesterol, and ask about lifestyle risks such as smoking and alcohol intake, to identify patients at risk of chronic diseases. </p>
<p>The prospect of saving money on GP visits might, for a moment, sound appealing to a government looking to <a href="https://theconversation.com/making-the-rich-pay-more-isnt-the-answer-to-a-better-medicare-23477">save on health spending</a>. But while pharmacists do need new roles, this should not be one of them.</p>
<h2>Community pharmacy under pressure</h2>
<p>There is a series of looming threats to the traditional community pharmacy. </p>
<p>The Guild <a href="http://www.guild.org.au/docs/default-source/public-documents/news-and-events/Community-Pharmacy-Under-Threat/pharmacy-under-threat-q-a.pdf?sfvrsn=0">claims that</a> price cuts announced by the Commonwealth in August last year could drive some pharmacists out of business. But as Grattan Institute reports <a href="http://grattan.edu.au/publications/reports/post/poor-pricing-progress-price-disclosure-isnt-the-answer-to-high-drug-prices/">have shown</a>, even after these cuts, Australia’s wholesale prices are still <a href="http://grattan.edu.au/publications/reports/post/australias-bad-drug-deal/">far too high</a>. For many drugs, the government still pays more than ten or 20 times the prices in New Zealand or the UK. These inflated prices cost taxpayers about $1 billion a year, as well as hitting consumers directly. </p>
<p>With the government searching for savings, inflated drug prices are a very good place to look. If Australia gets competitive prices, it would have a big impact on pharmacy income.</p>
<p>There is also increasing scrutiny on deals between pharmacies and drug companies, with the Australian Competition and Consumer Commission <a href="http://www.businessspectator.com.au/news/2014/2/13/health-and-pharmaceuticals/accc-slams-pfizer-court-case">taking a drug company to court</a> over discounts it gave pharmacies.</p>
<p>Finally, there is growing competition from discount pharmacies and supermarkets. In 2011, Terry White of Terry White Chemist <a href="http://www.kordamentha.com/docs/publications/publication-11-03-retail-pharmacy.pdf?Status=Master">saw many of these</a> changes coming: </p>
<blockquote>
<p>Pharmacists are going to cop it both ways. There’s the hit in the margins coming from back-of-shop and increased competition for sales in front-of-store. I have never seen it this tough.</p>
</blockquote>
<h2>Using pharmacists’ skills</h2>
<p>The bulk of government payments to pharmacists are mark-ups on drug prices. The more drugs pharmacists dispense, and the higher the price, the more money pharmacists make. For the most part, we’re paying them as retailers.</p>
<p>Yet, as many other countries have realised, pharmacists shouldn’t be valued by the cost of the pills they sell. They are trained for four years about drugs and their impacts. They know how to dispense drugs safely and provide advice on medicines. They are a highly trusted group located throughout Australia, including in areas with low access to primary health care. </p>
<p>People can usually see a pharmacist immediately. In many parts of Australia, this can’t be said of GPs. In cities, more than one in eight people report waiting too long to see a GP. In regional and rural areas, it’s about <a href="http://www.nhpa.gov.au/internet/nhpa/publishing.nsf/Content/Healthy-Communities-Australians-experiences-with-primary-health-care-2010-11/$file/HC-PatientExperience-2010-2011-Report.pdf">one in five</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/42335/original/fj3mfgt2-1393217572.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/42335/original/fj3mfgt2-1393217572.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/42335/original/fj3mfgt2-1393217572.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=724&fit=crop&dpr=1 600w, https://images.theconversation.com/files/42335/original/fj3mfgt2-1393217572.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=724&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/42335/original/fj3mfgt2-1393217572.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=724&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/42335/original/fj3mfgt2-1393217572.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=910&fit=crop&dpr=1 754w, https://images.theconversation.com/files/42335/original/fj3mfgt2-1393217572.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=910&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/42335/original/fj3mfgt2-1393217572.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=910&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p>In Britain, Canada, New Zealand and the United States, pharmacists are used to increase access to primary care. They deliver a wider range of services, including providing vaccinations, reissuing prescriptions for long-term conditions and working as part of a team to help patients manage chronic conditions. </p>
<p>It’s time for <a href="http://grattan.edu.au/static/files/assets/31e5ace5/196-Access-All-Areas.pdf">Australian pharmacists</a> to follow suit, particularly in rural areas where there is a chronic shortage of GP services.</p>
<h2>Why not start with one-off health checks?</h2>
<p>The Australian Medical Association (AMA) has denounced the $50 pharmacist health check proposal, arguing the direct cost to government would be higher than for a similar GP visit. That’s questionable, as GPs can bill $58 or $70 for a half-hour health check. </p>
<p>The AMA also <a href="https://ama.com.au/gpnn/pharmacy-health-checks-waste-taxpayers-money">raises concerns</a> about the quality of pharmacist check-ups, fragmentation of care, and possible lack of patient privacy during pharmacy consultations.</p>
<p>One of these concerns is certainly valid: a one-off check would do little to achieve integrated care. It would basically leave us with the same old model, missing an opportunity to adapt to the rise of chronic disease.</p>
<p>A growing number of people have chronic conditions such as diabetes, arthritis and heart disease – and they’re increasingly likely to have multiple health problems. This means they need to use several different health care services, often while taking a complex array of medicines. Providing the right mix of care in a seamless way that works for patients is a crucial challenge for health care in coming decades.</p>
<p>To make it work, pharmacists should do more than one-off health checks with no real link to other kinds of care. GPs should remain at the centre of the system, referring patients to other kinds of health worker as needed. </p>
<p>Making this change won’t be easy. Better patient records, training that helps different disciplines work together, and the right financial incentives and quality assurance will all help. While there are challenges, other countries have already done this, and there is <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3551433/">evidence that patients benefit</a> when pharmacists contribute to team-based care for chronic disease.</p>
<p>The Pharmacy Guild is clearly looking for new ways for its members to earn an income. That’s fine if it makes the whole system work better. But a one-off health check that doesn’t take broader issues into account won’t do that.</p><img src="https://counter.theconversation.com/content/23187/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Breadon does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Pharmacy Guild has proposed a scheme that would see the Commonwealth government pay pharmacists A$50 to provide one-off health checks. Pharmacists checks would assess patients’ body mass index, blood…Peter Breadon, Senior Associate, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/173522013-09-23T20:42:52Z2013-09-23T20:42:52ZShould only pharmacists profit from falling drug prices?<figure><img src="https://images.theconversation.com/files/31782/original/8jn8cwnk-1379917200.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Three consumer organisations have recently joined forces to campaign for cheaper medicines.</span> <span class="attribution"><span class="source">Waleed Alzuhair</span></span></figcaption></figure><p>The Consumers Health Forum has just <a href="http://ourhealth.org.au/drugged-reality-losing-2000-a-minute-and-counting">launched a website</a> containing information about the cost of generic drugs in Australia compared to other countries. Each day, Australians pay A$3 million more for these drugs than they would if they bought them in New Zealand or the United Kingdom.</p>
<p>The information on the website shows the cumulative cost of current medicines pricing policy. Unless the policy is changed, that A$3 million will add up to A$1 billion in lost savings by this time next year.</p>
<h2>How it works now</h2>
<p>In Australia, the prices for most drugs are set by the government through the Pharmaceutical Benefits Scheme (PBS). The government pays some of the highest prices in the world for generic drugs (medicines on which the patent has expired). </p>
<p>Take the commonly prescribed cholesterol-lowering drug atorvastatin, for instance. For a typical dose (40mg), the wholesale cost of a script in Australia is A$38. </p>
<p>The comparative cost in England and New Zealand for the same drug is less than A$3. Based on last year’s usage alone, atorvastatin cost the Australian government A$548 million; if it had paid English prices, the drug would have cost A$119 million and with New Zealand prices, it would have cost A$100 million.</p>
<p>Atorvastatin’s patent expired around 18 months ago and wholesale prices have been falling since as many new suppliers enter the market. </p>
<p>But the price paid for atorvastatin by the Australian government has remained high because the pricing of all generic drugs on the PBS is governed by an agreement that’s due to end in July 2014. </p>
<p>Under this agreement, a mechanism known as price disclosure sets future prices based on past wholesale cost of medicines to pharmacists. The problem with price disclosure is the rate of adjusting generic drug prices is too slow. </p>
<p>It currently involves collecting wholesale price information from the pharmaceutical industry for a year and it then takes another six months to implement the price changes. </p>
<p>So any discounts on the wholesale price of common generic drugs such as atorvastatin that flow to pharmacies do not translate into price reductions for the government or consumers for a period of up to 18 months.</p>
<p>Under current policies, pharmacies get to keep all of these discounts and they quickly add up to very large amounts. For a drug such as atorvastatin, more than A$400 million will flow to 5,200 pharmacies from wholesale discounts from the time it came off patent to December 2013.</p>
<h2>Moving towards a better model</h2>
<p>England also uses a system of price disclosure, but the cycle over which cost reductions are made is only three months – six times faster than what happens in Australia. </p>
<p>The figure below shows the current prices for the top eight generics in terms of total government expenditure in Australia and what we would pay if costs were equivalent to those in England.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/30979/original/rpt4sdmr-1378703117.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/30979/original/rpt4sdmr-1378703117.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/30979/original/rpt4sdmr-1378703117.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=639&fit=crop&dpr=1 600w, https://images.theconversation.com/files/30979/original/rpt4sdmr-1378703117.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=639&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/30979/original/rpt4sdmr-1378703117.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=639&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/30979/original/rpt4sdmr-1378703117.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=803&fit=crop&dpr=1 754w, https://images.theconversation.com/files/30979/original/rpt4sdmr-1378703117.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=803&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/30979/original/rpt4sdmr-1378703117.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=803&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p>The speed of adjustment clearly makes a lot of difference.</p>
<p>For the 20 most expensive generic drugs, Australia pays around A$1.8 billion each year, whereas if the government could pay English prices, that would be reduced to around A$735 million, a savings of A$3 million a day.</p>
<p>How could we spend less? A first step would be to ensure that policy reform adopted by the previous government in its last <a href="http://www.budget.gov.au/2013-14/content/economic_statement/download/2013_EconomicStatement.pdf">economic statement</a> is implemented. </p>
<p>Designed to take the first step towards speeding up the time it takes to adjust prices from 18 months to one year, the measure would return A$830 million from pharmacy owners to taxpayers or consumers. </p>
<p>In response to the changes, the Pharmacy Guild <a href="http://www.professionalpharmacy.com.au/older-australians-will-suffer-from-pbs-changes-guild/">ran a political campaign</a> arguing that up to 5,000 pharmacy jobs were under threat. And it indicated it wanted compensation for the changes. </p>
<p>It’s not clear if the new government will implement the reform and do more to reduce the prices of our most commonly used generic drugs.</p>
<h2>Deja vu</h2>
<p>Still, we have been here before. Tony Abbott introduced price disclosure in the final year of the former Howard government when he was health minister. He <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/9FCA731CD637B7ABCA257228002BAA26/$File/abb161106.pdf">said at the time</a> that it was a way to “harvest most of [the] discounts” that were accruing to pharmacy owners for taxpayers and consumers.</p>
<p>Abbott’s reforms included several hundred million in compensation for pharmacy owners for the loss of their discounts. But the payment was meant to be a one-off, <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/9FCA731CD637B7ABCA257228002BAA26/$File/abb161106.pdf">as he indicated in 2006</a>:</p>
<blockquote>
<p>The reason why the savings to government become much more significant in five years’ time and beyond is because there are about 100 major drugs that are coming off patent in that time and we are compensating pharmacists, we are explicitly compensating pharmacists for the loss of discounts over the next four years; but we are not explicitly compensating them for the much greater impact of the loss of discounts in the subsequent five and more years.</p>
</blockquote>
<p>The problem with the Abbott policy was that it was voluntary to supply real wholesale price data and industry chose not to do it for most drugs. </p>
<p>In the first round price disclosure reductions in 2009, the price of only four generic drugs fell. Commenting at the time, <a href="http://beta.guild.org.au/uploadedfiles/National/Public/Fact_Sheets/PBS_price_disclosure.pdf">the Pharmacy Guild claimed</a> that this debunked “myths about the extent to which community pharmacies are given discounts on generic drugs”.</p>
<p>Changes introduced by the former Labor government in 2010 were designed to fix these limitations, but their “accelerated” price disclosure was still <a href="http://www.theaustralian.com.au/news/health-science/drug-deal-costing-billions-medicines-australia/story-e6frg8y6-1225866384337">an extremely slow process</a> to reduce generic prices.</p>
<p>The most recent changes were simply a way of passing on these discounts more quickly to consumers and taxpayers. Isn’t it time all Australians shared in the discounts and got a slice of A$1 billion extra each year we are paying for common generic drugs?</p><img src="https://counter.theconversation.com/content/17352/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Philip Clarke provided the consumer organisations involved in lobbying for lower prices for medicines with information for their website. He was not paid for the information.</span></em></p>The Consumers Health Forum has just launched a website containing information about the cost of generic drugs in Australia compared to other countries. Each day, Australians pay A$3 million more for these…Philip Clarke, Professor of Public Health, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/100162013-03-18T19:52:36Z2013-03-18T19:52:36ZPharmacy gravy train drives up the cost of prescription drugs<figure><img src="https://images.theconversation.com/files/21375/original/fb6ch445-1363587280.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There's no requirement for pharmacies receiving taxpayers' money to do anything more than dispense medicines.</span> <span class="attribution"><span class="source">Ian Broyles</span></span></figcaption></figure><p>The retail pharmacy industry in Australia has successfully acquired a monopoly on supplying medicines paid for by the government or consumers. The industry describes this set-up as being the “<a href="http://www.guild.org.au/iwov-resources/documents/The_Guild/tab-News_and_events/Guild_News_Centre/2012/MR_mpa_website_15June12.pdf">best subsidized medicines scheme in the world</a>,” but consumers may beg to differ. </p>
<p>The government has a contract with pharmacies to dispense medicines listed on the <a href="http://www.pbs.gov.au/pbs/home">Pharmaceutical Benefits Scheme</a> (PBS) that cost more than $36.10 at a subsidised price. Let’s call this the co-payment threshold. The consumer pays the full price of any medicine that costs less than this. </p>
<p>A “<a href="http://www.medicareaustralia.gov.au/provider/pbs/pharmacists/safety-net.jsp">safety net</a>” applies to people spending $1,390.60 on medicines a year as well as pensioners and concession cardholders who fill more than 60 prescriptions in a calendar year. Pharmacies are allocated an approval number that allows them to claim the difference in the cost of drugs above the co-payment threshold from Medicare. </p>
<p>There are no specifications or monitoring for the renewal of this contract, which is automatically renewed with no quality control on the services being provided by approved pharmacies, or accountability to the funder (taxpayer) for work done.</p>
<p>Let it be known from the outset that the following critique doesn’t apply to all retail pharmacies; there are some that do better than others. The main point here is that there’s no requirement for pharmacies receiving taxpayers’ money to do anything more than the simple task of dispensing. </p>
<p>Now, let’s imagine there was no system and we were asked to design one that would give maximum benefit to consumers for the money being spent. First, it would have to ensure the product was available. This would be achieved through a network of agencies paid by the government to have a range of medicines available to fill patients’ prescriptions. Medicare would own the inventory of medicines that would be subsidised. </p>
<p>Another requirement would be to provide patients with <a href="http://circ.ahajournals.org/content/119/23/3028.full">information about the medicine</a>, at least the first time they buy it so they know what to expect and any side effects. A third would be to <a href="http://www.intelecare.com/downloads/ncpie-adherence-report.pdf">report what’s been collected</a> by which patient back to the clinician so that at their next visit, the clinician knows that the medicine was, in fact, taken as prescribed. </p>
<p>And the final element is an analysis of whether the medicine worked - for instance, was blood pressure actually lowered as the medicine claimed it would be or did it stay the same? This all sounds pretty simple but it’s not how the current system works because the supply system for subsidised medicines is being driven by vested interests and not consumer demand. </p>
<p>Regrettably, even in this technology-driven age, many consumers are unaware of the information they need to understand why medicines are important to them. Taking medicine for a chronic disease, for instance, is a prescription for life and adherence is necessary to avoid hospitalisation. </p>
<p>The reason for this deficit and others like it is the <a href="http://www.thepowerindex.com.au/power-move/pharmacists-wield-too-much-power-howard-advisor/20120124961">powerful lobby for the retail pharmacy industry</a> that insists the system that existed in 1950 should be maintained. And we pay considerable fees for pharmacies’ dispensing under the system. </p>
<p>In 2010-11, pharmacists received $6.42 each time a prescription was filled (this dispensing fee has increased to $6.52 now) – a total of $1.2 billion for filling 188.1 million prescriptions. This money represented <a href="http://www.pbs.gov.au/statistics/2010-2011-files/expenditure-and-prescriptions-2010-2011.pdf">13.6% of the total PBS cost</a> of $8,827 billion for the period. It doesn’t take into account the money received by way of the mark-up on the cost of the pharmaceuticals, which varied from as high as 15% for products priced up to $30, to 4% on medicines priced to $1,750. The consumer could well ask what are they’re getting for this fee.</p>
<p>For those buying a medicine with the total cost under the co-payment threshold of $36.10, there may also be a fee of $1.07 for the recording of safety net values and an additional discretionary charge of $4.04 that’s automatically included in pharmacy software packages. This extra charge is something that consumers should be made aware of but usually aren’t. </p>
<p>This can take the <a href="http://www.medicareaustralia.gov.au/provider/pbs/pharmacists/pricing.jsp#N102A4">total amount consumers pay</a> for a medicine to $11.63 in charges and fees alone, without adding the 15% mark up on cost by the pharmacy and the cost of the medicine itself. </p>
<p>Any lower cost for “generic” brands of previously patented medicines is passed on to the supplying pharmacy. This makes the generic medicine cheaper for the supplier but not necessarily to the consumer. Instead, consumers can end up facing the amazing situation of having to choose from up to <a href="http://www.pbs.gov.au/medicine/item/1889K-3300Q%20antibiotic%20(Amocycillin%20500%20mgm%20capsules">12 brands of a medicine</a> – all at the same price! </p>
<p>So what do we get for this extra cost and are pharmacists accountable for adding value to the medicine? Sadly, no. A signature by the consumer to say they received the medicine is all that’s required for the Commonwealth to pick up the bill from what the consumer pays. In many cases, the consumer has to pay the full cost of the medicine and this can act as a <a href="https://theconversation.com/why-automating-the-pbs-safety-net-will-be-good-for-everyone-3381">deterrent to adherence</a>. But there is no more accountability for the $2 billion to be paid out by the PBS. </p>
<p>What’s more, the agreement between pharmacists and the commonwealth is made between the <a href="http://www.guild.org.au/the_guild">Pharmacy Guild of Australia</a> and the minister for health despite the clear conflict of interest for the former, which is registered under the Trade Practices Act as an industrial organisation to benefit its members (the owners of retail pharmacies).</p>
<p>The current system of dispensing medicines could be done from an ATM-type machine for all the value that pharmacists add to their supply function. It becomes a production line process as each pharmacy tries to dispense quicker than its competitor.</p>
<p>A better way has to be found. One that allows a Pharmacare agency to sit alongside Medicare is not beyond the realms of possibility. This may bring pharmacies’ focus back to the health consumers’ benefit, and away from the vested interests of the pharmacy marketing cartel.</p>
<p>This is the first article in our short series about pharmacies. Click on the link below to read the other instalments:</p>
<p><strong>Part Two:</strong> <a href="https://theconversation.com/online-pharmaceuticals-bricks-not-clicks-keep-us-safe-12654">Online pharmaceuticals: bricks, not clicks, keep us safe</a></p>
<p><strong>Part Three:</strong> <a href="https://theconversation.com/note-to-pharmacists-on-how-not-to-sell-the-morning-after-pill-10250">Note to pharmacists on how not to sell the morning-after pill</a></p>
<p><strong>Part Four:</strong> <a href="https://theconversation.com/pharmacists-should-drop-products-that-arent-backed-by-evidence-12646">Pharmacists should drop products that aren’t backed by evidence</a></p>
<p><strong>Part Five:</strong> <a href="https://theconversation.com/why-you-have-to-show-id-to-buy-cold-and-flu-tablets-2173">Why you have to show ID to buy cold and flu tablets</a></p><img src="https://counter.theconversation.com/content/10016/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rollo Manning does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The retail pharmacy industry in Australia has successfully acquired a monopoly on supplying medicines paid for by the government or consumers. The industry describes this set-up as being the “best subsidized…Rollo Manning, Pharmacist & Adjunct LecturerLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/105832012-11-09T00:05:15Z2012-11-09T00:05:15ZFor your own good? Privacy law and enthusiastic pharmacists<figure><img src="https://images.theconversation.com/files/17425/original/gpxkgg7p-1352418061.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Any restriction on buying painkillers needs to be consistent with national privacy protection.</span> <span class="attribution"><span class="source">Nils Geylen</span></span></figcaption></figure><p>Earlier this week the ABC <a href="http://www.abc.net.au/news/2012-11-06/codeine-abuse-leads-to-calls-for-painkiller-rethink/4356816">reported</a> that a handful of pharmacists in Tasmania had engaged in community policing. They’re tracking the purchase of codeine-based painkillers, sharing information with their peers and refusing sales on the basis of that information. </p>
<p>Clearly, the road to privacy hell is paved with good intentions; these pharmacists are attempting to build a freeway that bypasses statutory protection. Their non-government initiative is supposedly justified by the need to protect people from codeine abuse. </p>
<p>The action is a private version of Project STOP, a government program that aims to restrict access to pseudoephedrine, which is a precursor of <a href="http://www.ndlerf.gov.au/pub/Monograph_39.pdf">methamphetamine</a>, aka speed or ice. Project STOP <a href="http://www.guild.org.au/iwov-resources/documents/The_Guild/PDFs/News%20and%20Events/Publications/Fact%20Sheets/project_STOP.pdf">provides</a> a real-time database for recording all requests for products containing pseudoephedrine.</p>
<p>The program provides decision support to pharmacists – “should I or shouldn’t I supply to this person?” – while also supplying real-time data to law enforcement agencies and health regulators. This data is provided regardless of where in the country people are buying pseudoephedrine-based products. </p>
<p>All such activity for the nation can be accessed from the one screen. This means people in every pharmacy across Australia can see when you try to buy pseudoephedrine-based cold tablets and stop the sale.</p>
<p>The tracking being undertaken by the Tasmanian pharmacists in the ABC report involves recording the license details of customers to stop codeine road trips. One of the pharmacists interviewed says,</p>
<blockquote>
<p>Project Stop hasn’t been approved for codeine sales, but we’re doing it because we think it’s the lesser evil to perhaps infringe on people’s personal privacy, to infringe on these privacy laws rather than allow a handful of people to do enormous damage to themselves.</p>
</blockquote>
<p>The pharmacists’ enthusiasm is laudable and it’s good to see them looking at more than the bottom line or sales of blue woolly bears, herbal supplements, jellybeans, cotton buds and other necessities. But it’s disturbing that personal notions of public health are able to override privacy law and consumer autonomy.</p>
<p>Building a bypass around law that individual pharmacists apparently regard as inappropriate is worrying because it erodes the trust we need to have in the gatekeepers of public health, such as pharmacists. They are the people, after all, who have access to information that is deeply private (you can tell a lot about a person on the basis of a prescription) and whose advice we need about the use of medications. </p>
<p>But this trust is eroded if consumers find the local chemist confuses the provision of prescriptions with policing and is actively tracking what consumers buy, with complete disregard for the law.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/17430/original/93zzv3gs-1352418922.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/17430/original/93zzv3gs-1352418922.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/17430/original/93zzv3gs-1352418922.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/17430/original/93zzv3gs-1352418922.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/17430/original/93zzv3gs-1352418922.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/17430/original/93zzv3gs-1352418922.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/17430/original/93zzv3gs-1352418922.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Elliott Brown</span></span>
</figcaption>
</figure>
<p>Unwise use of non-prescription drugs that can be quite legally purchased by consumers may well be a public health concern. So is misuse of alcohol. So are excessive fast food and jellybean consumption, given episodic moral panics about <a href="http://www.theatlantic.com/business/archive/2009/07/americas-moral-panic-over-obesity/22397/">obesity</a>. </p>
<p>But we don’t expect bottleshops and pubs to track our purchases. We don’t need to provide ID when we indulge in a hamburger and fries, pick up a pizza or buy an extra block of chocolate. We don’t expect a retailer to track what we are buying and refuse a sale on the basis of an idiosyncratic decision by private sector pizza police or chocolate cops. </p>
<p>Do we want and need extrajudicial codeine police? Or supermarkets tracking sales of Australia’s favourite drug – <a href="http://www-test.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737420455">tobacco</a> – and refusing sale if during the past month you have purchased more than what is considered appropriate?</p>
<p>Project STOP has been justified as inconveniencing outlaw motorcycle gangs and other entities that are engaged in the production and distribution of illegal drugs. Private restrictions on codeine are different. We need to be wary about private enthusiasm that disregards law. </p>
<p>If there’s a need to track and restrict the sale of ordinary painkillers, that need should be addressed in a consistent and transparent way that has a statutory basis. Restrictions certainly shouldn’t break the law. A disregard of the privacy protection that is the right of all Australians shouldn’t be justified on the basis that someone has a pharmacy degree, lives in a particular location and is well meaning. </p>
<p>The law applies equally to Philip Morris, the Pharmacy Guild, Telstra and the Commonwealth Bank. If pharmacists can disregard the law, why can’t police, and teachers and childcare workers and a plethora of other functionaries?</p>
<p>The Pharmacy Guild has indicated that it would support proposals to extend Project STOP to track codeine sales. The Guild acknowledges that such a move would require legislative changes. If we are going to restrict sales of legal painkillers we should do so nationally and we should ensure that restriction is consistent with national privacy protection – and that this protection isn’t disregarded by well-meaning enthusiasts.</p><img src="https://counter.theconversation.com/content/10583/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bruce Baer Arnold does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Earlier this week the ABC reported that a handful of pharmacists in Tasmania had engaged in community policing. They’re tracking the purchase of codeine-based painkillers, sharing information with their…Bruce Baer Arnold, Assistant Professor, School of Law, University of CanberraLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/59192012-03-23T03:48:52Z2012-03-23T03:48:52ZIs pharmacy the final frontier for supermarkets?<figure><img src="https://images.theconversation.com/files/8875/original/qxk4khy3-1332384028.jpg?ixlib=rb-1.1.0&rect=20%2C7%2C991%2C741&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pharmacy retailing is the last frontier for large supermarket chains.</span> <span class="attribution"><span class="source">Flickr</span></span></figcaption></figure><p>Australia’s two major supermarket retailers, Coles and Woolworths, already have vested interests in fuel, convenience, liquor, hardware, hotels, apparel, general merchandise and technology. While they continue to battle each other for a share of the household food shopping dollar, pharmacy appears the final opportunity to grow their business.</p>
<p>Yet, due to current legislative restrictions, Australian supermarkets are unable to follow global retail models like, Asda, Tesco, Sainsbury’s (UK), Walmart, Publix, Wegman’s (US) or French retailer, Carrefour, all of which have pharmacies inside most of their stores.</p>
<p>Prior to 2000, under the stewardship of Roger Corbett, Woolworths lobbied strongly for the opportunity to branch into pharmacy retailing. The 1999 Australian Parliamentary Inquiry into the retail sector recommended supermarkets should not expand into providing pharmacy services. </p>
<p>The committee noted that the role community pharmacists played in public health was unique and that the expansion by supermarkets into the dispensing of pharmaceutical products should be discouraged. The committee considered Australia’s system of community pharmacy to be one of the best in the world and hence, should not be changed.</p>
<p>In November 2005, then Health Minister Tony Abbott, advised that any push from supermarkets, to allow pharmacies to operate within their sites would be blocked - a ban Woolworths had been fighting to overturn. In 2007 current Health Minister, Nicola Roxon denied claims by online news outlet Crikey that Labor had agreements with Woolworths to allow the retailer to operative pharmacies or dispensaries in their supermarkets. The current <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/fifth-community-pharmacy-agreement">fifth Community Pharmacy Agreement</a> supported a continuation of inhibiting pharmacy co-location within supermarkets.</p>
<p>It is evident that supermarkets are still very interested in aligning with global retail trends and providing pharmaceutical services in their stores. With the current agreement in place until mid-2015, it is expected we will once again observe strong lobbying from both retailers. </p>
<p>Pharmacy appears as the last opportunity for the supermarket giants to jump on. They already have vested interests in liquor, fuel, hardware, technology, clothing, stationery, insurance, financial services and are actively moving into health. Big W’s move into optometry is a case in point. As a result, supermarkets have engaged significant market research to improve and grow this category. Australian shoppers today would already be seeing new aisle layouts, point-of-sale and signage implemented to make it easier for shoppers to select medicinal products.</p>
<h2>Time for another look?</h2>
<p>Is it time to re-evaluate at these restrictions on supermarkets? Would the inclusion of pharmacy consulting rooms in supermarkets provide the community a viable, affordable and more sustainable network of pharmacy dispensing services? </p>
<p>US supermarket retailers Giant, Publix Supermarkets, Stop n’ Shop and Wegman’s were the first to announce a program offering generic versions of various antibiotics free of charge for patients with prescriptions. They said, “We hope this program will offer added convenience and value to our customers during these challenging economic times.”</p>
<p>Would adopting a global retail operations framework, improve flexibility to respond to the community need for pharmacy services?</p>
<p>Consider US food retailers, Wegman’s or Giant, that offer consulting rooms, service counters, drive through windows and automated telephone services that allow customers to order prescriptions around the clock. Or, UK retailers Sainsbury’s and Asda, that offer online ordering of prescription and over-the-counter pharmaceuticals, automated dispensaries and virtual kiosks to remotely communicate with pharmacists. </p>
<p>So would pharmacy services, enveloped within supermarkets, improve local access for rural and remote regions and communities? </p>
<p>With a network of over 2000 supermarkets across Australia and extensive logistics and supply chain capabilities, could these retailers offer remote communities access to health education and benefits that urban dwellers take for granted. Could economies of scale reduce supply chain costs, leading to cheaper medicines for such communities and reduce pharmaceutical costs to governments? Such legitimate questions are worth asking.</p>
<p>Could our supermarkets alleviate the pressure on GPs, medical centres and hospital waiting rooms, by adopting a UK/US model? In Australia, from July 1, 2012, pharmacists will be able to re-issue regularly prescribed medicines, such as birth control and cholesterol lowering medications.* This will mean patients will not need to keep going back to GP to get repeat prescriptions. Will such a move present an opportunity for supermarkets?</p>
<p>Although considered a controversial idea, could we see suitably trained nurses or pharmacy assistants operating in supermarket consulting rooms, offering diabetes blood tests, inoculations, travel vaccinations, dietary advice and general health checks, such a blood pressure tests. In UK supermarket Asda offers £7 flu shots. Would such a move reduce waiting times in medical centres and hospitals and provide doctors, nurses and other medical professionals more time to treat the seriously ill?</p>
<p>Further, could such private enterprise provide funds for capital projects at a much larger scale ever seen, removing this cost from governments and indirectly all Australian tax payers?</p>
<h2>A precautionary note</h2>
<p>It is important to recognise that community pharmacy plays an important role in the Australian healthcare system. There are approximately 5000 pharmacy-owned community pharmacists in Australia, employing over 12,000 university-qualified pharmacists and approximately 30,000 trained pharmacy assistants.</p>
<p>A recent Pharmacy Guild of Australia survey found that 62% of surveyed Australians sought information about medicines or the treatment of a minor illness from a community pharmacist in the past year. </p>
<p>Further research has also discovered that quality advice, fully trained pharmacy assistants and trust is the single most important competitive advantage pharmacy has to offer.</p>
<p>The atomised interaction with a supermarket checkout operator will not be - and is not suggested to be - a suitable alternative for the continuing personal relationship of care, patients share with their pharmacist, or doctor. I would suggest the Australia consumer would never accept such an ideal.</p>
<p>Importantly, healthcare is not a commodity. It cannot be bought and sold like a can of baked beans or a bottle of milk. Choice among different brands is problematic enough for customers shopping for consumer goods and services. Unlike low involvement goods, when purchasing over the counter medicines, the customers demand for quality advice and trust is vitally important.</p>
<p>When the consumer is ill, what matters most is the relationship of trust that can enable them to negotiate the imbalance of knowledge and expertise in their encounters with pharmacists and doctors. Unless a carefully considered model is developed, we will never see pharmacies in supermarkets. </p>
<p><em>*The original article incorrectly said pharmacists would be able to re-issue blood pressure medication. This reference has been removed to correct the error.</em></p><img src="https://counter.theconversation.com/content/5919/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gary Mortimer does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Australia’s two major supermarket retailers, Coles and Woolworths, already have vested interests in fuel, convenience, liquor, hardware, hotels, apparel, general merchandise and technology. While they…Gary Mortimer, Senior Lecturer, QUT Business School, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/33182011-11-18T03:20:55Z2011-11-18T03:20:55ZConsumers need the facts about complementary medicines<figure><img src="https://images.theconversation.com/files/5171/original/Peter_Sunna.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Vitamins, minerals and herbal therapies should live up to the claims on their packaging.</span> <span class="attribution"><span class="source">Peter Sunna</span></span></figcaption></figure><p>Two out of three Australians use complementary medicines to boost their nutrition, alleviate various symptoms and improve their overall health and well-being. There are around 10,000 products to choose from and they’re not cheap – the industry generates around <a href="http://www.anao.gov.au/%7E/media/Uploads/Audit%20Reports/2011%2012/201112%20Audit%20Report%20No%203.pdf">$1.2 billion in sales</a> each year. </p>
<p>Despite the availability and common use of these vitamins, minerals, herbal remedies, aromatherapy and homeopathic products, consumers can’t always be sure how effective they are.</p>
<p>While pharmaceutical companies are required to prove the quality, safety and efficacy of prescription drugs and over-the-counter medicines to the <a href="http://www.tga.gov.au/">Therapeutic Goods Administration</a> (TGA) before they’re “registered”, complementary medicines aren’t required to live up to the claims on their packaging. </p>
<p>Rather, complementary medicines are “listed” by the TGA after being reviewed for safety and quality only. </p>
<p>The quality requirement means the medicine is produced by a licensed manufacturer and <a href="http://www.anao.gov.au/%7E/media/Uploads/Audit%20Reports/2011%2012/201112%20Audit%20Report%20No%203.pdf">adheres to the Good Manufacturing Principles</a>. The safety requirement is important because the components and content of active ingredients can vary, particularly among herbal products.</p>
<p>The difference between registered and listed products, and whether they’ve proved their efficacy, is often not clear to the consumer.
And as we saw with Ken Harvey’s recent battle with <a href="http://theconversation.com/sensaslim-and-me-how-criticism-of-a-weight-loss-spray-landed-me-in-court-1911">Sensaslim</a> over allegations of false and misleading advertising, consumers can’t always believe the claims made by manufacturers about the efficacy of complementary medicines. </p>
<p>The public backlash after the Pharmacy Guild announced its (now defunct) plan to <a href="http://theconversation.com/one-wrong-foot-after-another-the-ethics-of-the-pharmacy-guilds-deals-3939">recommend Blackmores products</a> to patients filling a prescription for four common ailments also shows consumers feel confused and misled about the efficacy of complementary products.</p>
<p>The TGA is expected to address this problem in the coming weeks
by announcing that <a href="http://www.theage.com.au/national/unprescribed-remedies-to-go-under-the-microscope-amid-efficacy-concerns-20111117-1nl2f.html">complementary medicines will soon have to carry a “not tested” label</a>. </p>
<p>But labels alone wouldn’t provide enough information to consumers, who want to know whether the medicine works. For that, testing is required. </p>
<p>So how should these therapies be tested? And should the same rules that are applied to prescription and over-the-counter medicines be applied to complementary medicines? </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/5629/original/mywellnesscentre.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/5629/original/mywellnesscentre.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=225&fit=crop&dpr=1 600w, https://images.theconversation.com/files/5629/original/mywellnesscentre.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=225&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/5629/original/mywellnesscentre.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=225&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/5629/original/mywellnesscentre.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=283&fit=crop&dpr=1 754w, https://images.theconversation.com/files/5629/original/mywellnesscentre.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=283&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/5629/original/mywellnesscentre.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=283&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">How can you measure therapies that harness human energy?</span>
<span class="attribution"><span class="source">mywellnesscentre</span></span>
</figcaption>
</figure>
<h2>Evidence-based testing</h2>
<p>Pharmaceuticals are subjected to a series of <a href="http://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/evidence_statement_form.pdf">randomised controlled studies</a> to demonstrate their effectiveness. And while <a href="http://summaries.cochrane.org/search/site/complementary">some complementary medicines have undergone similar rigorous reviews</a> to demonstrate their efficacy, the idea of such evidence-based testing is problematic for many complementary and alternative medicine practitioners. </p>
<p>Practitioners of complementary medicines work in many different ways and their patients have varied goals. </p>
<p>Some complementary therapies, such as homeopathy and acupuncture, are based on the assumption that the human body has an energy level, with therapies having a physiological impact via the energy level. How could this be tested?</p>
<p>As Wainwright Churchill noted in an article in the <a href="http://www.jcm.co.uk/product/catalog/product/view/7610/implications-of-evidence-based-medicine-for-complementary-alternative-medicine/">Journal of Chinese Medicine</a>, in order to test the efficacy of complementary medicines, you would first need to address some difficult questions:</p>
<ul>
<li><p>Should the treatment that is researched be individualised for each patient? </p></li>
<li><p>Does it involve the personal relationship between the treating health professional and patient? </p></li>
<li><p>Does it involve the patient’s expectations, conscious or unconscious, of the treatment? </p></li>
</ul>
<p>This leads us to the role of the placebo: Is the placebo effect a valid healing modality?</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/5631/original/rutty.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/5631/original/rutty.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/5631/original/rutty.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/5631/original/rutty.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/5631/original/rutty.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/5631/original/rutty.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/5631/original/rutty.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Flickr/rutty</span></span>
</figcaption>
</figure>
<p>Sceptics deride the placebo. And yet, the placebo effect is powerful in all therapeutic relationships, in allopathic and complementary medicine. To be effective, <a href="http://www.scientificamerican.com/article.cfm?id=placebo-effect-a-cure-in-the-mind">placebos don’t even require conscious belief</a> in a particular treatment.</p>
<h2>Lesson learned</h2>
<p>In determining a process by which complementary medicines should be evaluated, regulators should look to Switzerland for some lessons on what to avoid. </p>
<p>In the late 1990s, the Swiss government began a Program for Evaluating Complementary Medicine (PEK – <a href="http://www.bag.admin.ch/themen/krankenversicherung/00263/00264/04102/index.html">Programm Evaluation Komplementärmedizin</a>). </p>
<p>The findings of the evaluation were inconclusive but six years later, five complementary therapies were removed from the list of services covered by the national health insurance scheme. This occurred <a href="http://panmedion.org/files/PEK-Einleitung.pdf">before all parts of the review had been completed</a> and the process was far from transparent. </p>
<p>Recently, the Swiss government decided that from 2012 the five complementary therapies that had been removed from the health insurance scheme <a href="http://www.swissinfo.ch/ger/politik_schweiz/Komplementaermedizin_bleibt_auf_dem_Pruefstand.html?cid=29234668">will be included again</a>, at least for another six years. During that time, the organisations representing the five therapies will have to prove their effectiveness.</p>
<p>In Australia, consumers need reliable information about the effectiveness of all medicines, complementary or otherwise. The TGA’s plans to slap an “untested” label on complementary medicines simply isn’t enough. </p>
<p>It’s clear, however, that this world-first style of regulation won’t be easy. Regulators need to find testing methods that are acceptable to the majority of stakeholders – I’m not going to hold my breath but I hope we can one day achieve this goal.</p>
<p><em><strong>Should complementary medicines be tested for efficacy? Share your comments below.</strong></em></p><img src="https://counter.theconversation.com/content/3318/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Monika Merkes' self-managed superannuation fund owns shares in Blackmores.</span></em></p>Two out of three Australians use complementary medicines to boost their nutrition, alleviate various symptoms and improve their overall health and well-being. There are around 10,000 products to choose…Monika Merkes, Honorary Associate, Australian Institute for Primary Care & Ageing, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/39392011-10-20T06:39:40Z2011-10-20T06:39:40ZOne wrong foot after another: the ethics of the Pharmacy Guild’s deals<figure><img src="https://images.theconversation.com/files/4677/original/3050802125_4df86436a3_b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Pharmacy Guild has a deal that encourages pharmacists to sign up patients to Pzifer's support programs.</span> <span class="attribution"><span class="source">Marcus Q</span></span></figcaption></figure><p>First it was the <a href="http://theconversation.com/pharmacies-to-push-supplements-as-fries-and-coke-to-prescriptions-3578">Pharmacy Guild’s deal with Blackmores</a> that raised ethical concerns. Now it’s the Guild and Pfizer. </p>
<p>Both deals involve undisclosed payments from drug companies to Guild subsidiaries to ensure that dispensing software identifies certain prescriptions on which pharmacists are prompted to take action. </p>
<p>In the Blackmores case, to on-sell Blackmores “companion” complementary medicines with prescription drugs; in the Pfizer case to sign up patients prescribed nine Pfizer brand name drugs to the company’s “support” programs. </p>
<p>Pfizer Australia CEO John Latham has argued that their deal is totally different from Blackmores. Pharmacists are merely being paid a $7 “administrative fee” for the time taken to sign up a patient. </p>
<p>Latham said the deal costs the patients nothing and supports quality use of medicines. </p>
<p>Patients who sign up, for example to Pfizer’s cholesterol-lowering medication program, receive weekly emails, advice and access to support tools encouraging medication adherence, healthy diet and exercise. </p>
<p>So what’s wrong with that? </p>
<p>First, although pharmacists obtain consent for patient contact details to be made available to Pfizer, pharmacists apparently don’t inform the patient that they get paid for each referral. </p>
<p>In my opinion health professionals should disclose such remuneration as an integral part of obtaining informed consent. </p>
<p>Second, I believe that a drug company directly conducting such programs has its own conflicts of interest. </p>
<p>One of the patient support programs recommended, for instance, is for Pfizer’s blockbuster cholesterol-lowering medicine Lipitor (generic name atorvastatin). </p>
<p>This drug loses its patent early next year and will face intense competition for more cost-effective generic versions. </p>
<p>Although the disclosed aim of the Lipitor support program is to improve health outcomes, an undisclosed aim may well be to enhance brand loyalty. </p>
<p>The result could be that enrolled patients will be less likely to accept generic substitution when the Lipitor patent expires. </p>
<p>There’s <a href="http://www.mja.com.au/public/issues/185_09_061106/nel10178_fm.html">good evidence</a> that poor patient adherence to important medication can result in poor health outcomes. </p>
<p>There’s <a href="http://www2.cochrane.org/reviews/en/ab000011.html">also evidence</a> that certain interventions can enhance medication adherence.</p>
<p>However, in my view such programs should not be run by drug companies because their need to maximise profits (for example by promoting brand loyalty) may override the patients’ interests of swapping to a more cost-effective generic drug. </p>
<p>In addition, drug company “educational / promotional” material often maximises product benefits while minimising potential adverse effects. </p>
<p>It will not provide comparative information about the pros and cons of alternative brands. </p>
<p>My own preference is for patient information to come from independent sources such as the <a href="http://www.nps.org.au/">National Prescribing Service</a>.</p>
<p>The Pharmacy Guild’s involvement in such schemes is equally problematic. The Guild’s membership includes 5000 owners of community pharmacies and while it provides a powerful lobby for owner’s self-interest it does not represent the many more professional pharmacists who have expressed concern about such deals. </p>
<p>For example, the pharmacists’ union - the Association of Professional Engineers, Scientists and Managers Australia have said the Pfizer deal was yet another example of the owners’ guild abusing the good name of pharmacists to boost profits. They have called for it to be abandoned. The Consumers Health Forum has also expressed concern. </p>
<p>The Guild national president, Kos Sclavos, rejected suggestions these programs could undermine the confidence patients have in pharmacists. </p>
<p>“These programs have been around for two decades,” he said. </p>
<p>However, times change and community and health professional attitudes also change. Some years ago one medical software vendor did a lucrative deal with a number of pharmaceutical companies to run advertisements for the latest and most expensive pharmaceuticals flashing up in doctor’s prescribing computers, all day, every day. </p>
<p>This caused a public outcry from both <a href="http://www.mja.com.au/public/issues/183_02_180705/har10263_fm.html">health professionals and consumers</a> and it was ultimately abandoned both by the software vendor and Medicines Australia (the prescription industry body). The Code of Conduct of the latter now says, “Advertisements for prescription products must not be placed in any section of prescribing software packages.” </p>
<p>I would hope that the Pharmacy Guild and their dispensing software subsidiary will come to a similar conclusion about prompts from drug companies in their own software.</p><img src="https://counter.theconversation.com/content/3939/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ken Harvey does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>First it was the Pharmacy Guild’s deal with Blackmores that raised ethical concerns. Now it’s the Guild and Pfizer. Both deals involve undisclosed payments from drug companies to Guild subsidiaries to…Ken Harvey, Adjunct Associate Professor of Public Health, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.