Who is the real winner in the latest stoush between pharmacists and doctors?

Last week a state Pharmacy Guild president made a few negative comments about general practice. I thought it was neither here nor there, but what happened next was interesting.

I could not find the original column (admittedly I didn’t look very hard) so I can’t verify his exact words but apparently, he said that increased funding for GPs will only incentivise five-minute ‘turnstile’ medicine.

Most GPs would not have read or been aware of the column until, on the eighth of February, Australian Doctor Magazine, owned by the Australian Doctor Group (ADG), posted an article on their website titled “Pharmacy Guild says GPs working ‘turnstile operations’ filling time-slots with easy patients.”

Then all hell broke loose. There were 170 comments on the article from mostly angry GPs.

A few days later, on the eleventh of February, Pharmacy News published this piece: “Guild takes aim at GPs who favour wealthy, healthy patients”. 

Interestingly, Pharmacy News is also owned by ADG.

Then the response came. On the thirteenth of February a reply penned by the RACGP president was published. And you guessed it, that same day Australian Doctor posted: “Turnstile, cream-skim medicine? RACGP hits back at Pharmacy Guild.”

The ADG publications got hundreds of clicks and views of their website content out of the latest stoush between pharmacists and doctors.

Good on them, one could argue. But hang on, there’s more to it. The ADG website explains how it works:

“We know that GPs are increasingly time-poor and less reliant on [pharmaceutical] sales reps,” says Bryn McGeever, Managing Director of Australian Doctor Group. “They’re looking elsewhere for information.”

“While readership of medical print publications remains strong, digital channels are becoming increasingly popular with almost eight in 10 GPs now reading online medical publications monthly.”

“In recognition of this continuing shift in GP behaviour, Australian Doctor Group last week launched AccessPLUS, a bespoke digital sales channel designed to fill the space left behind as rep engagement continues to fall.”

And the real winner is….

It is sad, but not surprising, that the medical media are fuelling the tensions within primary care. Of course, like other media, ADG is just doing its job. I do wonder how many GPs and pharmacists are aware that they are the product on sale here.

I have had my fair share of altercations with the Pharmacy Guild – but it’s a road to nowhere. I prefer to listen to people like pharmacist Debbie Rigbie, who rightly says, “We must build bridges across our differences to pursue the common good.”

This is how your data in the My Health Record will be used

On Friday the Federal Government quietly released its long-awaited framework for secondary use of information contained within the My Health Record. It will generate discussion as it is controversial.

The release of the framework to guide the secondary use of My Health Record (MyHR) system data comes just months before the participation rules for the Australian national health record change from opt-in to opt-out.

Consent for secondary use is implied if consumers don’t opt out of the MyHR. In other words, people need to take action if they don’t want their health data to be used for purposes other than direct clinical care.

To stop information flowing to third parties, consumers will have to press the ‘withdraw participation button’.

Another hot topic is the use of the data by commercial organisations which, interestingly, is permitted under the framework, provided it is ‘in the public interest’.

And, as expected, one of the main purposes of secondary use is the monitoring of outcomes of care. It remains to be seen what this will mean for the interaction and relationship between consumers and health providers.

The release of data is expected to commence from 2020.

Commercial use

The Australian Institute of Health and Welfare (AIHW) will act as the data custodian.

A ‘My Health Record secondary use of data governance board’ will assess applications for access to MyHR data ‘based on the use of data, not the user’.

Any Australian-based entity, except insurance companies, can apply to get access to the data. The board will take a ‘case and precedent’ approach to determining what uses will be permitted and not permitted for secondary use.

Although information in the MyHR cannot be used for commercial purposes, such as direct marketing to consumers, data may be released to commercial organisations if they can demonstrate that the use is consistent with ‘research and public health purposes’ and is likely to be ‘in the public interest’.

I suspect that this backdoor will be in high demand by third parties such as the pharmaceutical industry.

The board can permit the linkage of myHR data with other data sources once the applicant’s use is assessed to be of public benefit. In an example provided in the framework, researchers link MyHR information to a database of clinical trial participants to investigate hospitalisations, morbidity and mortality.

Data may also be linked to other datasets such as hospitals, MBS, PBS and registry data.

Examples

The framework gives examples of the use of health data for secondary purposes, including:

  • Evaluation of health interventions and health programs (e.g. determine if an intervention or service is generating outcomes/benefits consistent with funding approvals)
  • Examining practice variations for the purposes of quality improvement or adherence to best-practice guidelines at a health service level
  • Construction of clinical registries (e.g. create or supplement data in clinical registries to evaluate the effectiveness of interventions)
  • Improvement of existing health services and development of new services
  • Enhancing post-market surveillance insights for new products
  • Improvements to patient pathways research
  • Increased visibility and insights into population health matters
  • Development of government health policy
  • Develop/enable technology innovations
  • Preparation of publications
  • Recruitment to clinical trials (e.g. identify people who may be suitable for a new product/service)
  • Development of clinical decision support systems (e.g. link data on individual’s health with best practice to influence treatment choices)
  • Health services research relevant to public health (e.g. examine the health service utilisation patterns for potentially avoidable hospitalisations; research that leads to changes in other government policies, such as welfare, and ultimately reduces impact on the health system).

A review will be performed after two years, which may identify additional uses.

The MyHR 'withdraw participation button’
Consumers can stop their My Health Record (MyHR) data being used for secondary purposes by pressing the ‘withdraw participation button’.

Not permitted 

The following uses of MyHR data are not permitted:

  • Determination of funds allocation for a health service (e.g. set the level of funds allocated to an individual community health service)
  • Remuneration of individual clinicians (e.g. to make/modify payments)
  • Individual clinician audit (note: this does not exclude examining practice variations for the purposes of quality improvement or adherence to best-practice guidelines at a health service level).
  • Direct marketing to consumers
  • Assessment of insurance premiums and/or claims
  • Assessment of eligibility for benefits (e.g. use by Centrelink and/or the Australian Taxation Office to make determinations relating to an individual)
  • Criminal and/or national security investigations, except as required by law (e.g. use to investigate the interactions of individuals with the health system as part of assessing their behaviour).

Withdrawing participation

Data that has been removed or classified by consumers as ‘restricted access’ will not be retrieved for secondary use purposes. Similarly, when people cancel their MyHR record, the data will no longer be used.

Consumers can stop their data being used for secondary purposes by clicking on the ‘withdraw participation button’. It is expected that a dynamic consent model will be introduced later, which allows consumers to give consent for secondary use on a case-by-case basis (which would also open the door for the use of identified data).

In the light of the recent Facebook Cambridge Analytica Scandal I suspect that many consumers will press the button – or will be advised by health professionals to do so.

Doctors vs corporates: who’s winning?

When trying to inform government policy, the medical profession is often up against lobbyists representing large corporate commercial interests. This usually does not improve patient care. It is also difficult for patients to distinguish between groups that advocate for the public good versus those that are after increased profits, power or influence. Below are some examples.

There are strong indications that funding for after-hours medical services in the community is used inappropriately. For example, I have received reports from some of these services (who mostly employ non-GPs) delivering repeat prescriptions after-hours to patients’ homes. After-hours visits classified as “urgent” attract a Medicare rebate of $130–$150 compared to non-urgent visits of $55 and $36 for standard GP surgery consultations.

The after-hours industry is booming.

Let’s look at the ACT: since the arrival of the bulk-billing National Home Doctor Service in the capital, home visits rose from 1588 in 2013–14 to 20,556 in the last financial year. This trend is seen at a national scale and there is no reasonable explanation for the steep rise in home visits.

What we need is ethical and efficient after-hours deputising services that work seamlessly with day-time medical services.

After a pushback by the profession and the launch of a Medicare Benefits Schedule (MBS) Review Taskforce, the National Association for Medical Deputising Services started an aggressive lobbying campaign to “protect home visits”.

Although several after-hours services recently quit the lobbying group – including the Canberra After-Hours Locum Medical Service, the Melbourne-based DoctorDoctor service and the Western Australian Deputising Medical Service – the campaign is still ongoing.

Big pathology

Another example of an influential lobbying group is Pathology Australia, representing several big corporations, which converted their public “Don’t Kill Bulk Bill” campaign to a backdoor deal with the government to reduce the rent they pay to GP practices for co-locating their pathology collection rooms.

The response from the Royal Australian College of General Practitioners (RACGP) was that the proposed changes will create an anticompetitive environment, propping up multinational corporations that make hundreds of millions of profit each year, while GPs running small businesses lose funding on top of the ongoing MBS freeze.

The Australian Medical Association also made it clear that this proposal went too far, interfered with legitimate commercial arrangements that have been entered into by willing parties, and that it would damage medical practices.

Pathology Australia made five donations to political parties in the last financial year alone, totaling $69,600.

Big vitamins and pharmacies

A recent episode of Four Corners once again revealed the influence of the Big Vitamins industry, selling their unproven complementary products via community pharmacies.

Complementary Medicines Australia, a lobbying group representing the complementary medicines industry, argued on the program that, despite lack of evidence, there was a role for homeopathy and that “some consumers do find that it works”.

The Pharmacy Guild of Australia does not oppose the sale of unproven products, such as homeopathic ones, via community pharmacies.

The medical profession has been calling for more transparency about efficacy for years. RACGP president Dr Bastian Seidel said that the current retail business model of pharmacies, which allows products like vitamins and supplements to be sold to Australians, is inappropriate within the health care environment, and that these products must not be sold as complementary or alternatives to evidence-based medicines prescribed by a doctor.

Health consumers also have concerns: the Consumers Health Forum of Australia reiterated in a media release, following the broadcasting of the Four Corners episode, that the Therapeutic Goods Administration (TGA) does not include a check of the efficacy of most complementary products, and that a clear signal from the TGA about the therapeutic worth of these products is required.

The Pharmacy Guild made 37 donations to political parties in the last financial year alone, totaling $236,530.

There are other examples, such as the private health industry lobby and of course Medicines Australia, the pharmaceutical manufacturer lobby group. The Grattan Institute estimated that if the Department of Health kept vested interests out of the Pharmaceutical Benefits Scheme policymaking, taxpayers would save $320 million a year. As the Grattan Institute put it: “Seeking the advice of drug company lobbyists gave the foxes a big say in the design of the hen house”.

Medicines Australia made 17 donations to political parties in the last financial year, totaling $82,212.

Pressure

It appears that there is increasing pressure from a broad range of big corporations and lobby groups on the health care sector. I believe this usually does not improve patient care and, in some cases, will adversely influence health outcomes.

It is clear that politicians and decision makers are being heavily lobbied by these organisations, and the questions arise: will they be able to withstand these forces, and are they able to make decisions in the best interest of Australians – even though this may not always be popular?

This article was originally posted in MJA Insight

Follow me on Twitter: @EdwinKruysDisclaimer and disclosure notice.

The drug rep and our illusory superiority

The drug rep and our illusory superiority
Image: Pixabay.com

The attitude of doctors towards pharmaceutical sales representatives (‘drug reps’) is influenced by a complex psychological phenomenon, and we seem to be blissfully oblivious.

About twenty years ago I briefly studied psychology at the University of Amsterdam. It’s a long time ago, but two things I still remember. One: the psychological experiments we had to submit ourselves to as first year students to get enough points to pass – so senior students and scientists would have sufficient study participants. And two: the Milgram experiment.

Shocked by Milgram

This well-known experiment shocked the world in 1963. Yale university psychologist Stanley Milgram showed that many study participants obeyed an authority figure in a white coat, even if this meant they had to administer dangerously high shocks to other participants.

I still recall watching the film at the university, in horror. I couldn’t believe that the poor participants would follow a request to these extremes. I was certain that I would have disobeyed the experimenter.

The Milgram experiment was replicated in 2006 – with some changes to satisfy the research ethics committee – and guess what: The results were similar. Most participants agreed to administer increasingly painful shocks when asked to by a professor.

I was probably wrong in thinking that I would have disobeyed. Yet at the same time I wasn’t, because most people believe they would not follow the order to administer the shocks.

The psychological phenomenon of self-deception

So why are we fooling ourselves? It’s called illusory superiority: an illusion of personal strength. This phenomenon has been demonstrated in countless experiments. For example, a study asking people to rate their own driving skills demonstrated that eighty per cent of drivers rate themselves above-average.

Illusory superiority occurs in a variety of circumstances:

In an article titled Shallow thoughts about the self, a group of authors argues that we tend to mistake our good intentions for our actual behaviour.

Our inability to recognise bias

Similarly most people think they are less susceptible to bias than others. This failure to recognise our own bias is caused by the bias blind spot.

One study found that 52% of doctors agreed doctors were influenced by the pharmaceutical industry, but 40% believed this was not the case for them personally.

So, when the friendly drug company representative comes along, serves lunch, and gives us little gifts to make us prescribe their product, we may think we’re not susceptible to their influence and strong enough to form our own opinion – but are we really?

The no advertising please campaign encourages doctors not to use drug reps as a source of education. I have signed the pledge not to see drug reps in the next 12 months.