Chapter 1
Introduction
Terms of Reference
1.1
On 24 March 2011 the Senate referred the following matter to the Senate
Community Affairs References Committee for inquiry and report:
The effectiveness of the special
arrangements established in 1999 under section 100 of the National Health
Act 1953, for the supply of Pharmaceutical Benefits Scheme (PBS) medicines
to remote area Aboriginal Health Services (AHSs), with particular reference to:
(a)
whether these arrangements adequately address barriers experienced by
Aboriginal and Torres Strait Islander people living in remote areas of
Australia in accessing essential medicines through the PBS;
(b)
the clinical outcomes achieved from the measure, in particular to
improvements in patient understanding of, and adherence to, prescribed
treatment as a result of the improved access to PBS medicines;
(c)
the degree to which the ‘quality use of medicines’ has been achieved
including the amount of contact with a pharmacist available to these patients
compared to urban Australians;
(d)
the degree to which state/territory legislation has been complied with
in respect to the recording, labelling and monitoring of PBS medicines;
(e)
the distribution of funding made available to the program across the
Approved Pharmacy network compared to the Aboriginal Health Services obtaining
the PBS medicines and dispensing them on to its patients;
(f)
the extent to which Aboriginal Health Workers in remote communities have
sufficient educational opportunities to take on the prescribing and dispensing
responsibilities given to them by the PBS bulk supply arrangements;
(g) the degree to which recommendations from previous reviews have been
implemented and any consultation which has occurred with the community
controlled Aboriginal health sector about any changes to the program;
(h)
access to PBS generally in remote communities; and
(i) any other related matters.
1.2
The initial reporting date was 18 August 2011 however on 29 June 2011,
the Senate granted an extension of time for reporting until 11 October 2011.
1.3
The committee received 29 submissions. Due to the comprehensive nature
of submissions received by the committee, no public hearings were held.
1.4
The committee is grateful to submitters for assisting them in the course
of the inquiry, and to the Commonwealth Department of Health and Ageing (DOHA)
and the Queensland Government for responding to questions on notice.
Framework for the supply of PBS medicines in Australia
1.5
The Commonwealth government subsidises a wide range of prescription
drugs under the Pharmaceutical Benefits Scheme (PBS). Items included in the PBS
are subsidised to make them accessible and affordable. Each time a prescription
is filled, the patient pays an amount that is often much less than the actual
cost of the drugs. In 2011, the general patient contribution is $34.20 and the
concessional patient contribution is $5.60.[1]
1.6
PBS medicines are dispensed through a network of approximately 5000
community pharmacies. These privately owned and operated pharmacies are
represented by the Pharmacy Guild of Australia.
1.7
Five year Pharmacy Agreements between the Commonwealth and the Pharmacy
Guild of Australia govern arrangements for community pharmacies to be remunerated
for dispensing PBS medicines and to provide pharmacy programs and services. The
current Pharmacy Agreement sets out rules for the operation of Community
Services Obligation arrangements which provide financial support to
pharmaceutical wholesalers to supply the full range of PBS medicines via
community pharmacies, usually within 24 hours of ordering, and regardless of
where these pharmacies are located.
1.8
While the arrangements for the provision of PBS medicines through
community pharmacies described above may provide good access for most
Australians, people who do not live in areas where community pharmacies are
located will find accessibility and affordability much more difficult.
Special arrangements for the supply of PBS medicines to AHSs
1.9
Special arrangements for the supply of PBS medicines to Aboriginal and
Torres Strait Islander people in remote communities are in place in order to
improve access and use of PBS medicines. The two main programs are:
(a) The section 100 supply program, which provides payments to community
pharmacies for dispensing PBS medicines in bulk to remote area Aboriginal
Health Services (AHSs).
(b)
The section 100 pharmacy support allowance, which provides payments to
community pharmacists to help AHSs improve the way that their patients use PBS
medicines.
1.10
Collectively these two programs are known as the Remote Area Aboriginal
Health Services (RAAHS) program. A number of other programs have direct and
indirect impact on the operation of the RAAHS program and will be referred to
in the course of this report.
1.11
Section 100 of the National Health Act 1953 (National Health Act)
provides for special arrangements to be made to ensure that an adequate supply
of pharmaceutical benefits will be available to people living in isolated
areas. The RAAHS program operates under this provision and provides for PBS medicines
to be dispensed in bulk through community pharmacies and hospital authorities
to Aboriginal Health Services. These medicines are supplied, at no cost to
patients, by doctors, nurses or Aboriginal Health Workers (AHWs). In this sense
PBS medicines provided under this program are 'free' to patients.
1.12
The section 100 supply program commenced in 1999. Participation in the
scheme is, with a few exceptions, limited to AHSs operating in remote areas.
1.13
In order to be able to participate in the program, the community
pharmacy or hospital authority, as well as the remote area AHS, must be approved
by DOHA in order to carry out relevant functions. The PBS items must be dispensed
directly by a pharmacist or hospital authority to the remote area AHS. PBS
medicines are then supplied to patients of the AHS by a qualified and approved
health professional in accordance with relevant state and territory law.[2]
1.14
Medicare Australia reimburses the supplying community pharmacist or
hospital authority.[3]
1.15
The National Health (Remote Aboriginal Health Services Programs)
Special Arrangements Instrument 2010 sets up the eligibility criteria for
the assessment and approval of AHSs.
1.16
Health services must meet eligibility criteria set out below:[4]
(a)
The health service must have a primary function of meeting the health
care needs of Aboriginal and Torres Strait Islander peoples.
(b)
The clinic, or other health care facility, operated by the AHS from
which pharmaceuticals are supplied to patients must be in a remote zone as defined
in the Rural, Remote and Metropolitan Areas (RRMA)[5]
Classification 1991 Census Edition.
(c)
The AHS must not be a party to an arrangement, such as a coordinated
care trial, for which funds from the Pharmaceutical Benefits Scheme have
already been provided.
(d)
The AHS must employ or be in a contractual relationship with health
professionals who are suitably qualified under relevant state/territory
legislation to supply all medications covered by the section 100 arrangements
and undertake that all supply of benefit items will be under the direction of
such qualified persons.
(e)
The clinic or other health care facility operated by the AHS from which
pharmaceuticals are supplied must have storage facilities that will:
(i)
prevent access by unauthorised persons;
(ii)
maintain the quality (eg chemical and biological stability and
sterility) of the pharmaceutical; and
(iii)
comply with any special conditions specified by the manufacturer of the
pharmaceutical.
1.17
Information on the DOHA website indicates that the remuneration and
claims system for pharmacists and hospital authorities participating in the
program operates in the following way:
The Australian Government reimburses pharmacies and hospital
authorities under the section 100 Remote Program for pharmaceutical benefits
supplied by approved health services.
The remuneration is the sum of the approved price to
pharmacists, mark-ups, as appropriate for the cost of the item and a handling
fee.
The approved price and mark-up are defined under section
98B(3) and 98B(1)(a) of the Act respectively. Current mark-up amounts are
detailed by Medicare Australia...
The handling fee historically was $1.14 and temporarily
increased by $1.55 to $2.69 per Pharmaceutical Benefit Schedule (PBS) item
supplied. This was the result of discussions between the Australian Government,
the Pharmacy Guild of Australia, and a number of individual pharmacists. This
increase was included as a measure in the 2009-10 Federal Budget and was
effective from 1 January 2009 to 30 June 2010 at a cost of $3.1 million.
[An] Ongoing increase to the section 100 handling fee was
announced in the 2010/2011 Budget. The fee was increased to $2.74 on 1 July
2010, and will be indexed annually.[6]
Purpose of the program
1.18
The section 100 supply program commenced in 1999 in response to the low
use of PBS medicines by Aboriginal and Torres Strait Islander people in remote
areas relative to other Australians. The program was introduced after a review[7]
of PBS expenditure showed that Aboriginal and Torres Strait Islander people in
both urban and remote areas had reduced access to PBS medicines compared with
non-Indigenous people. The Centre for Remote Health notes that this review
found that that there was only 33c spent on the PBS for Aboriginal and Torres
Strait Islander people compared with $1 for non-Indigenous people, with this
comparison subsequently being used as a measure of access to the PBS.[8]
1.19
Research by the Australian Institute of Health and Welfare (AIHW) shows
that current Medicare expenditure is much lower for Aboriginal and Torres
Strait Islander people than that for non-Indigenous Australians, with 57 cents
per dollar being spent on Aboriginal and Torres Strait Islander people. In
relation to the use of the PBS, the Indigenous to non-Indigenous expenditure
per person ratio is 0.74. The only PBS service type with a high expenditure
ratio occurs under RAAHS program.[9]
1.20
The Centre for Remote Health puts it in another way:
The AIHW last year estimated that [per person expenditure]
had risen to 60c per dollar. However, the same report found that in Remote/very
remote areas, Indigenous Australians received PBS expenditure of $23 more per
person than non-Indigenous Australians (a ratio of 1.12). It attributes this to
the fact that Section 100 arrangements allow patients attending an approved
remote area Aboriginal and Torres Strait Islander health service to receive PBS
medicines without the need for a prescription form and at no charge.[10]
1.21
It is well known that the prevalence of chronic disease in remote Aboriginal
and Torres Strait Islander communities is much higher than in the general
Australian population, with many factors contributing to this situation.
Barriers to the use of medicines to treat chronic disease include levels of
English and health literacy, the ability to understand instructions for use of
medicines, cultural issues around taking medicines and accessing services,
concurrent use of bush or traditional medicines, issues related to continuity
of care and forming relationships with health practitioners, as well as
geographical isolation and physical access to health services.[11]
1.22
DOHA’s submission to the inquiry states that geographical, cultural and
financial issues impact on access to PBS medicines by Aboriginal and Torres
Strait Islander people in remote areas.[12]
Aboriginal and Torres Strait Islander people living in remote communities can
experience delays in obtaining medicines through standard prescription-based
supply arrangements due to the shortage of both prescribers and pharmacists
with established services in these remote areas. They may face difficulty in
demonstrating their eligibility for PBS concessional benefits, and they may
also have difficulty in affording medicines. The RAAHS program tries to
overcome these barriers.
1.23
DOHA has provided the committee with the following information:
From its inception in 1999, the RAAHS Program has grown from
servicing 35 remote Aboriginal Health Services to 173 in 2011.
The supply of PBS items has increased from around 250,000 in
1999-2000 to more than 1.4 million in 2010-11.
In 2010-11, expenditure under the RAAHS Program had grown to
$43 million from $3.9 million when it commenced in 1999.
Around 170,000 Aboriginal and Torres Strait Islander people
are estimated to benefit from the increased access to PBS medicines and better
quality use of medicines activities.[13]
1.24
Program expenditure and participation is shown in the tables below.
|
Fin
year |
2006-07 |
2007-08 |
2008-09 |
2009-10 |
2010-11 |
|
Total
exp |
26.8 |
32.9 |
34.1 |
37.3 |
43.0 |
Table
1: RAAHS Program PBS expenditure 2006-07 to 2010-11 ($ million)[14]
|
|
Community operated |
State/Territory
operated |
Total |
|
NSW |
5 |
- |
5 |
|
NT |
25 |
54 |
79 |
|
Qld |
5 |
39 |
44 |
|
SA |
5 |
2 |
7 |
|
Tas |
2 |
- |
2 |
|
WA |
17 |
19 |
36 |
|
Total |
59 |
114 |
173 |
Table
2: Number of AHSs by State and Territory approved to participate in the RAAHS
Program[15]
1.25
Participating AHSs are either community-controlled services, or are
operated by state or territory governments in Western Australia, South Australia,
Queensland or the Northern Territory. Of the 173 AHSs currently participating
in the program, the majority of these are state/territory government-run AHSs. Only
one third of participating services are Aboriginal Community Controlled Health
Services (ACCHSs).
1.26
The National Aboriginal Community Controlled Health Organisation
(NACCHO) has advised the committee that ACCHSs are distinct from state and
territory government-run services and private general practices on the basis
that they are governed by an Aboriginal body elected by the local Aboriginal community
and are not for profit services.[16]
1.27
DOHA advised the committee that Memoranda of Understanding (MOUs) were
agreed between DOHA and the governments of the Northern Territory, Queensland,
South Australia and Western Australia to facilitate their participation in the
program.[17]
Queensland Health has advised the committee that the MOU between the state of
Queensland and DOHA expired on 31 December 2009.[18]
The committee understands that this is true for all jurisdictions, and there
are no current MOUs. While there are no MOU in place, services under the RAAHS
program are continuing to be provided, with a framework for their operation set
out in the National Health (Remote Aboriginal Health Services Program) Special
Arrangements Instrument 2010. The instrument covers some of the areas that were
contained in the MOUs, such as eligibility criteria for participation in the
scheme, aspects of the protocols for participation, such as how stock is to be
obtained and dispensed, and how remuneration for items is to be determined.
Other aspects of the MOUs are absent from the regulation, in particular how
savings achieved through the program are to be assessed and used.[19]
Exploring options for new MOUs with state/territory
governments to strengthen reporting requirements and to ensure ongoing
consistency of the MOUs with the program's objective of meeting the health care
needs of Aboriginal and Torres Strait Islander people.[20]
1.28
In Queensland, the Northern Territory and Western Australia where these governments
manage remote AHSs, a tender process for the supply of pharmacy services under the
section 100 program is used.[21]
This tender process has evolved to include state or territory-specific conditions
and means that the supply model can differ significantly between the states and
the Northern Territory. [22]
1.29
The committee notes that non-Indigenous people may be recipients of PBS
medicines under the program as the section 100 supply arrangements apply to all
clients of remote AHSs. As Ngaanyatjarra Health Service points out, it is the
only provider of health services to both Indigenous and non-Indigenous people
in the region, which approximates an area greater to that of the state of
Victoria.[23]
1.30
The committee is interested to note that the number of participating
health services in New South Wales and South Australia is relatively low
considering the population of Aboriginal and Torres Strait Islander people
living in remote areas in these states.
Section 100 Pharmacy Support Allowance
1.31
The section 100 pharmacy support allowance complements the section 100
supply program. It commenced in 2001 and funds the provision of services from a
pharmacy to AHSs in order to improve the way in which patients use the
medicines that are supplied under the program.
1.32
The allowance is an amount of between $6000 and $10 500 per annum per
AHS. The program also provides for a flat rate of $6000 to be paid in relation
to outstations attached to AHSs. For the purposes of the program, these
outstations must be a:
...remote permanent health service, staffed by at least one
permanent healthcare worker, where prescription only (‘Schedule Four’)
medicines are stored in compliance with an approval issued by the relevant
State/Territory health authority.[24]
1.33
Payment of the allowance is based on the amount of PBS items supplied
each year and travel loadings are calculated on distance from the supplying
pharmacy to the AHS. In addition, another loading is payable if the AHS is on
an island or if aircraft or boat transport is required to attend the AHS.
1.34
The Community Pharmacy Kit, developed by the Pharmacy Guild of Australia
and DOHA to support participants in the program, states that services under the
section 100 pharmacy support allowance should include:
-
Developing and implementing a work plan for supply arrangements
within the AHS;
-
Providing assistance to implement appropriate procedures and
protocols for managing supply arrangements, including establishment of a
medicine store;
-
Developing a range of other measures to enhance the quality use
of medicines (which may include assistance with dose administration aids, participation
in regular meetings with health staff, and review of patient medication);
-
Implementing agreed measures which aim to enhance quality use of
medicines; and
-
Providing a range of education services to AHS clinical and
support staff relating to medicines and their management.[25]
1.35
Like the section 100 supply program, applications are assessed by DOHA
and payments made by Medicare Australia.
Quality Use of Medicines
1.36
Quality Use of Medicines (QUM) is the name of a policy described by DOHA
as ‘one of the central objectives of Australia’s National Medicines Policy’.[26]
QUM means managing medicine treatment options wisely, choosing suitable
medicines if a medicine is considered necessary, and using medicines safely and
effectively.[27]
The Centre for Remote Health describes QUM as:
...ensuring patients know how to take [their medicine], why
they should take it, what alternatives there are to taking medicines, what will
happen if they don’t take it, possible side effects they should look out for
and how will they know if it is helping them?[28]
1.37
The section 100 pharmacy support allowance is designed to provide specific
services to AHSs that lead to improved use of medicines by their patients.
Other support programs
1.38
Workforce programs designed to attract more workers into pharmacy in
rural areas are in operation, such as the Aboriginal and Torres Strait Islander
Scholarship Program for pharmacy studies and the Rural Pharmacy Workforce
Program’s Scholarship for people from rural areas.
1.39
DOHA says that these programs:
...increase the likelihood of a larger rural pharmacy
workforce, and potentially lead to more pharmacists being available to provide
QUM support visits to remote AHSs. In addition, there is the Aboriginal and
Torres Strait Islander Pharmacy Assistant Traineeship Program. This Program
aims to increase the number of Indigenous health workers employed as pharmacy
assistants. Such people could be well placed to work directly for remote AHSs
and to support QUM activities.[29]
QUMAX and PBS Co-payment Relief
Measure
1.40
Two other PBS co-payment schemes operate to improve access to PBS
medicines for Aboriginal and Torres Strait Islander peoples, but these do not
apply to patients of remote area AHSs. QUMAX, or Quality Use of Medicines
Maximised for Aboriginal and Torres Strait Islander People, commenced in 2008 and
is jointly administered by NACCHO and the Pharmacy Guild of Australia.
1.41
NACCHO explains the program’s application and impact in the following
way:
QUMAX was developed jointly by the Pharmacy Guild of
Australia and the National Aboriginal Community Controlled Health Organisation
under the 4th Community Pharmacy Agreement in 2006-07. It commenced a program
of intensive QUM support, provision of dose-administration aids (DAA’s),
transport support and co-payment relief in 2008 until 30 June 2010, in
non-remote ACCHSs. Thereafter, the co-payment relief function was transferred
to the PBS co-payment relief measure (CTG scripts). QUMAX continues to provide
DAA’s and substantial QUM support to 2015 under the 5th Community
Pharmacy Agreement.
QUMAX has been highly successful at increasing medicines
access for ‘needy’ and disadvantaged Aboriginal peoples by eliminating
co-payment across 70 ACCHSs in nonremote locations.
Between November 2009 and April 2010, the proportionate
increase in the number of PBS medicines dispensed to patients of non-remote
ACCHSs was nearly five times greater than the increase in medicines dispensed
to all Australians, and exceeded the increase seen in remote areas (SECTION 100)
by a factor of seven.[30]
1.42
The PBS co-payment relief measure under the Indigenous Chronic Disease
Program is based on a person self-identifying as an Aboriginal or Torres Strait
Islander person and then being eligible for registration with Medicare
Australia to participate in the program:
...through either a private general practice registered with
the Indigenous Practice Incentive Program (PIP) and living anywhere in
Australia; or an ‘Indigenous Health Service’, if the service is in a nonremote area.
Once PIP registered, the general practice receives an incentive payment from
Medicare Australia, and if the patient is deemed eligible they can have their
PBS scripts annotated ‘CTG’ (Close the Gap), to receive either free medicines
or significantly reduced co-payments for medicines.[31]
1.43
There are no QUM activities linked with the CTG co-payment measure.
1.44
While these programs do not apply to patients of remote AHSs the
committee has considered it important to refer to the programs for three reasons:
firstly they provide examples of other schemes in operation; secondly because
the QUMAX scheme specifically includes funding for dose administration aids (DAAs)
which are compartmentalised boxes or blister packs designed to provide a
specific dose of medication, raised as an issue by a number of submitters
during the course of this inquiry and thirdly because there seems to be a high level
of frustration that each of the programs do not integrate with each other when
they are specifically designed to target a highly mobile population.
Outreach Pharmacists for Remote
Aboriginal and Torres Strait Islander Health Services
1.45
The Outreach Pharmacists for Remote Aboriginal and Torres Strait
Islander Health Services (OPRAH) program is run by the National Prescribing
Service (NPS)[32]
and provides training to pharmacists to develop the skills required to work
directly with AHSs. The OPRAH program operates on a very small budget,
estimated at $60 000 for the 2010-11 year and a budget yet to be approved
for the 2011-13 years but anticipated to be $140 000.[33]
This program aims to train 45 participants a year[34]
who participate in structured training and attend workshops designed to improve
their ability to support quality use of medicines in AHSs.
Good Medicines Better Health
1.46
The Good Medicines Better Health program is also funded by the NPS to
train Aboriginal Health Workers to support their colleagues in the quality use
of medicines. It is based on the 'train the trainer' model, with approximately
60 AHWs expected to complete training as trainers over the three year program
which ends in 2014.[35]
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