Pharmacy vax claims need a pinch of salt

The success of new health services in community pharmacies should be measured by the way they integrate and communicate with the rest of primary care including general practice.

A trial in WA reported earlier this month that more than 15,000 influenza vaccinations were administered last year with no adverse effects. The Curtin University researchers declared the program a success, saying there was scope to expand pharmacist vaccination services to other vaccines and younger children.

Recently we’ve heard about the ‘success’ of pharmacy trials in several states. However, the question arises: by what measure are the trials a success?

Many of my patients tell me they’ve been vaccinated at a pharmacy but have forgotten where, when and with what exactly – and communication from the pharmacy is usually missing.

One of my frail elderly patients who came to see me for something else declined a government-funded influenza vaccination by our practice nurse because she was booked in to have a private vaccination at the pharmacy the following week, and felt she couldn’t cancel that appointment.

This goes against the argument that pharmacy vaccinations are only targeting people who don’t have a GP, or people who fall outside the national immunisation program.

Walk-in convenience at pharmacies is often mentioned as a benefit of the scheme, but the preferred model seems to be an appointment during specific pharmacy trading hours.

Narrow vision of health

Public health arguments, such as increased vaccination rates, are intuitively compelling; to a public health advocate, it doesn’t matter where vaccinations are delivered.

Most of these stand-alone models have failed to look at the impact on primary care as a whole

However, most of these stand-alone pharmacy models have failed to look at the impact on primary care as a whole, including general practice teams, at a time when primary care is supposed to be moving towards more integration and collaboration.

Other issues that have often been overlooked are clinical benefit to the public, costs to the patient and health system, and conflicts of interest within the pharmacy industry.

Data reported from Queensland immunisation trials, for example, were superficial, selective and showed elements of observer bias. The trials did not reveal evidence about the impact on vaccine-preventable disease outbreaks. There was no comparison with alternatives, such as walk-in vaccination clinics in general practice.

The impact of missed opportunities for screening and other preventive care in general practice was not looked at, and neither did the trials focus on much-needed better integration of care delivery.

Yet, there is ample evidence that increasing general practice comprehensiveness of care is associated with decreasing costs and hospitalisations. Each time a task is given to other providers, the effectiveness and safety of our current proven GP-model is eroded, and this will ultimately have consequences for the care delivered to Australian communities.

Communication, upselling and out-of-pocket costs

The trials also failed to look at whether the standard elements of privacy, documentation or GP notification were met.

Furthermore, there has been no mention of whether commercial practices have been monitored, such as using vaccinations as a means to onsell other products. There is a well-known potential conflict of interest in pharmacists delivering health services including vaccinations.

Australians already pay more out-of-pocket costs than in many other countries

One of the strengths of medication prescribing in Australia is the high degree of separation between the prescriber and the medication dispenser. It enables more objective prescribing, free of pecuniary interests and leads to better allocation of resources. This is another strong argument against moving more health services into the pharmacy environment.

However, it seems that the goal posts are shifting.

Australians already pay more out-of-pocket costs than in many other countries. It is likely that health services delivered in the commercial pharmacy environment will further increase costs to patients. For example, administration of the quadrivalent influenza vaccine by WA pharmacists came at a cost of $30-$40.

Not surprisingly, the recent Review of Pharmacy Remuneration and Regulation posed 140 thought-provoking questions about the current community pharmacy model. It is hoped that some of the issues will be resolved as a result of the review.

It is clear to me that the claimed success of pharmacy vaccinations has to be taken with a pinch of salt.

If community pharmacy is able to better integrate their services with the rest of primary care, including general practice, the resulting model has the potential to become truly successful.

This article was originally published in Australian Doctor magazine (edited).

We told you so: Ignoring primary care is never a good idea

Last night’s undecided election results raise many questions – and doctors will say: we told you so.

Family doctors have made it very clear during the lead-up to the federal election that it’s crucial for governments to invest in primary care to keep Australians well and out of hospital.

But not only that, during the longest election campaign in Australia’s history, GPs around the country have had discussions with millions of patients about the future of their healthcare.

Looking at the outcome of the election night, it seems that voters have taken the message to the polling booths.

Wealth should not affect our health

The day after the federal election date was announced, the Royal Australian College of General Practitioners (RACGP) launched the You’ve been targeted campaign, warning people about the looming higher out-of-pocket costs, which have already become a reality.

The aim of the campaign was not to increase health corporate profits or fill doctors’ pockets, it wasn’t even a political campaign – it was all about the message that the Australian people must be able to visit their doctor when they need to.

Doctors called on a newly elected government to invest in quality and sustainable general practice to strengthen patient services.

“Our first and foremost responsibility is to our patients,” said RACGP President Dr Frank Jones, “and this is really the message from the College in the campaign, because this is about the fact that we cannot sustain quality general practice under the present Medicare freeze.”

Posters went up in GP surgeries, messages were printed at the bottom of prescriptions, TV ads were aired and there were 2340 syndicated media stories featuring the RACGP on national TV, print and radio, and in medical and consumer media outlets across all formats.

The Australian Medical Association (AMA) followed suit and threw its weight behind the issue, and shortly after many political parties made health a key focus during the election campaign. The policy shift by Labor to lift the Medicare freeze and fund chronic disease management by general practice teams was welcomed by many.

What should happen next?

Whatever the outcome of the election will be, the new government would do well to sit down with GP leaders and develop a long-term plan to strengthen primary care. The message is simple and supported by abundant evidence: strong primary care keeps people well and out of expensive hospitals. Investing in general practice patient care pays off!

Dr Frank Jones: “The RACGP is seeking progressive health reform and a genuine commitment to the future of our healthcare system from our political leaders and we are committed to discussing funding models for a sustainable and effective primary health care system.”

As GPs around the country are moving away from bulk billing, health minister Susan Ley has already indicated she is prepared to look at a medical home model. The proposed appointment of a National Rural Health Commissioner and commitment of the Coalition to pursue a National Rural Generalist Training Pathway is another positive sign.

However, the medical home is more than a hospital avoidance project. “In a patient-centred medical home, patients have a stable and ongoing relationship with a general practice that provides continuous and comprehensive care throughout all life stages,” said Dr Jones. “This model is the most cost-effective way to address the needs of patients, healthcare providers and funders.”

There are many versions of the medical home or healthcare home. The ‘gold standard’ version is outlined in the RACGP’s Vision for General Practice and a sustainable healthcare system.

Part of the future plan should be the continuation of high quality primary care research and the introduction of non-face-to-face patient services such as video consultations to improve access to family doctors and to transform Australian primary healthcare to the digital age.

The baby, the bathwater and a better health system

So we have a healthcare funding problem. Although there seems to be an appetite for change, it’s essential not to throw the baby out with the bathwater.

Our fee-for-system hasn’t done a bad job. Australians are healthier and live longer compared to many other countries, and our primary care sector is delivering cost-effective care.

On the other hand, as a result of population ageing, advanced technologies and new treatments, care becomes more expensive. Care needs are increasingly complex and require more interventions by a larger number of health professionals.

Our current fee-for-service may not be the best funding model for people with chronic and complex health problems, as it does not reward certain aspects of care – such as coordination.

The Federal Government is aiming for a ‘healthier’ Medicare and intends to find better ways to look after people with complex and chronic diseases, and keep people out of hospital longer. As part of this strategy the Primary Health Care Advisory Group (PHCAG) has been established to advise the government on reforming primary health care.

The PHCAG recently released a discussion paper and individuals, peak bodies and consumer organisations have responded with submissions. The advisory group’s recommendations for government are expected by the end of the year.

The future vision

The Royal Australian College of General Practitioners has, after consultation with members and external organisations, developed the ‘Vision for general practice and a sustainable health system’. If implemented, it will keep the benefits of fee-for-service for acute care, while improving care for people living with chronic and complex health problems.

The current Medicare Benefits Schedule discourages GPs from spending the time required with patients who have chronic and complex health issues. The system is based on face-to-face contact with patients – while care coordination and teamwork does not always involve the physical presence of the patient.

Consumers would like to see a healthcare model that empowers patients; they want less fragmentation and better integration and coordination of care.

To solve these issues, the RACGP made a range of recommendations in its submission to the PHCAG, based on the freshly developed vision. Essential components of the submission are voluntary patient enrolment and, in addition to the fee-for-service model, the provision of supplementary funding to support a range of patient services not currently or appropriately recognised.

Benefits of the medical home

Voluntary patient enrolment for all patients – not just for those with chronic and complex health conditions – ensures enduring relationships between patients, their personal GP and extended healthcare team, allowing for better targeted and effective coordination of clinical resources to meet patient needs.

There are four main benefits of voluntary patient enrolment:

  1. Practices will have a better understanding of their patient population and can better tailor services to the needs of their community.
  2. A stable and enduring relationship between a patient and a GP has a positive impact on health outcomes.
  3. It will benefit prevention and management of chronic diseases.
  4. Linking chronic disease management Medicare item numbers to a patient’s medical home will make sure funding for chronic disease management is directed efficiently and effectively.

Patients may choose whether or not to enrol in a medical home. Likewise, GPs and practices may choose to participate in the program.

Patients will be able to access standard consultations through any general practice, but chronic disease management, integration of care and preventive health will be limited to their medical home.

Implementing the medical home will need both initial and ongoing investment. However, any investment will result in cost savings, as efficiencies in the system are achieved.

New funding models

The introduction of support for GPs and their teams to undertake coordination work on behalf of their patients is essential and will stimulate multidisciplinary teamwork. This includes direct and efficient (electronic) communication between providers, and GPs need to be able to delegate care coordination responsibilities within a team.

A comprehensiveness payment made to a practice would recognise the practices and practitioners that offer a broad range of services to the community. The payment would be based on a defined breadth of item numbers used within a defined time.

The current incentives (PIP and SIP) need to be replaced by practitioner support and practice support payments as outlined in detail in the RACGP vision.

Reporting of de-identified patient data can be useful for the purposes of informing health system planning, but the college does not support the reporting of individual patient’s health outcomes or a pay-for-performance system. There is no evidence to suggest that reporting health outcomes improves the quality or safety of care, and there are no successful overseas models that can be adopted.

The cost of delivering quality care within the general practice setting is significant and increases annually in line with wages, consumables and infrastructure costs. It is imperative that Medicare patient rebates keep pace with the increasing costs of delivering quality care, so the freeze on Medicare rebates must be lifted.

General practice in Australia delivers efficient and cost-effective care. It is clear that health systems focusing on primary care have better health outcomes and lower use of hospitals. Now is the time to strengthen primary care – but let’s not throw the baby out.

This article was originally published in The Medical Republic.