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Medicine review changes hard to swallow

Critics say reduced frequency will lead to more incorrect dosages and hospitalisations. 

Aged care groups have struck out over what they call arbitrary changes to medication management programs funded under the Fifth Community Pharmacy Agreement. However, those administering the FCPA schemes say they have failed to live within their means.

The changes, announced February 12 and implemented March 1, mean Home Medicines Reviews (HMRs) and Residential Medication Management Reviews (RMMRs) will be funded once every two years per patient, instead of yearly under the previous terms of the agreement. On the provider side, HMRs have been capped at 20 per calendar month. RMMRs are not capped.

The Pharmacy Guild, which takes over administrative responsibility for the programs from the Department of Human Services under the changes, says they are necessary to ensure the programs remain within budget until the FCPA expires in June 2015.

“All of these changes are about making the best use of available funds to deliver the best possible services to patients who most need them,” Pharmacy Guild national president George Tambassis says.

A spokesman for the health minister acknowledged the value of HMRs and RMMRs but says programs and services under the FCPA must “live within their means”. He says the government is asking pharmacists to target the services for those who will gain the most from them.

But Aged and Community Services Australia (ACSA) says the changes could lead to a raft of serious problems for those in residential care: increased hospitalisations; missed medications; incorrect dosages and lack of monitoring generally.

ACSA is concerned that people may be denied medication reviews that are clinically warranted, and is calling on the government to overturn the changes.

“It just doesn’t add up in terms of the cohort that needs to be focused on,” ACSA CEO professor John Kelly says. “We’ve made it very clear that people who require reassessment will miss out, and may leave this world before they get a reassessment.”

The average stay for residents in aged-care facilities is just over two years, entitling them, on average, to one Medicare-funded medication review. About three-quarters of medication management reviews are performed on people over the age of 65.

ACSA says it will continue to push for the changes to be overturned within the life of the current pharmacy agreement.

The Pharmacy Guild, however, downplayed the impact of the changes, saying if a clinical case could be made for an RMMR or HMR to be performed more than once every two years, the review would be funded. A guild spokesman also estimates that the HMR cap will affect only 3 per cent of providers.

But critics of the agreement say the money allocated to medication reviews under the FCPA – a nominal increase in RMMR funding and a nominal cut in HMR funding – was never sufficient to reflect the trend in uptake, which outstripped funding over the life of the fourth agreement.

Brisbane-based consultant pharmacist and immediate past president of the Australian Association of Consultant Pharmacy, Debbie Rigby, says the budgetary problems are due in part to a growing acceptance of pharmacists performing HMRs and RMMRs.

The jury is in on the worth of medication management reviews as a preventive health measure, which is noted by the guild, government, GP groups and in a wealth of medical literature. Rigby, who estimates she has personally performed thousands of medication reviews during her time as an accredited pharmacist, relates a case that illustrates why.

“I had a lady that was on Warfarin, and she stored all her drugs under the kitchen sink along with her dog’s,” Rigby says. “Warfarin looked just like her dog’s heart worming tablet. The GP referred me (for an HMR) because they couldn’t stablilise her dose of Warfarin. I’m not sure who came off worse, her or the dog.”

Evaluating the environment in which people take medication is equally important in residential care facilities, she says: “Most of the time, residents have the drugs administered by the nurse. But are they crushing drugs that shouldn’t be crushed? Not giving them at the right times in relation to food? It’s not just about how doctors prescribe drugs, it’s about how nurses administer them.”

The FCPA between the Australian Government and the Pharmacy Guild of Australia began on July 1, 2010, and will provide $15.4 billion in funding for about 5000 community pharmacies over its five-year life. Of that, $52.11 million is allocated to HMRs and $70 million to RMMRs.

As preliminary negotiations commence for the Sixth Community Pharmacy Agreement, insiders are bearish about seeing a significant rise in funding for medication management reviews, despite evidence of widespread benefits to patient care.

The Australian Commission on Safety and Quality in Healthcare estimates that medication-related hospital admissions total 230,000 annually, at a cost of about $1.2 billion.

Neither the guild nor the government would comment on allegations a small number of providers had rorted the system by billing for higher quantities of HMRs than were reasonable or feasible.


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