GPs concerned over ‘disruptive’ fluticasone PBS restrictions

Anastasia Tsirtsakis

5/04/2023 4:05:45 PM

Patients aged six and under will now have to be seen by a paediatrician or respiratory physician to access a PBS script for the asthma medication.

A child using an orange inhaler.
Patients aged six and older will no longer be eligible for a PBS subsidy for fluticasone propionate 50 micrograms.

GPs will no longer be able to prescribe fluticasone propionate 50 micrograms under the Pharmaceutical Benefits Scheme (PBS) to patients aged six and under, unless they have first been seen by a non-GP specialist.
The change, effective as of 1 April, applies to the General Schedule (Section 85) listing for fluticasone propionate 50 microgram/actuation inhalation 120 actuations medication (sold as Axotide Junior and Flixotide Junior), which is indicated for the prophylactic management of asthma.
It means patients aged under six who are starting the treatment will need to be initiated by a respiratory physician or a paediatrician, after which a GP or nurse practitioner will be able to prescribe continuing treatment.    

Dr Kerry Hancock, Chair of RACGP Specific Interests Respiratory Medicine, told newsGP the changes are ‘disruptive’ to asthma management and come at a time when GPs are already inundated.
‘It’s confusing for GPs … [and] is just one more thing to have to deal with on top of everything else that GPs are dealing with at the moment,’ she said.
‘And, most importantly, it’s confusing for patients because they don’t understand the nuances of the PBS and the Pharmaceutical Benefits Advisory Committee [PBAC]. They just know that when they’re going to go to the pharmacy, they either cannot get their script dispensed or they have to pay extra.’
Dr Tim Senior, who is a member of Asthma Australia’s Professional Advisory Council, has been vocal about the changes on Twitter.
A GP at the Aboriginal Community Controlled Health Service in Southwest Sydney, he told newsGP the changes have real health equity consequences.
‘There are no bulk billing paediatricians in Campbelltown anymore and that’s going to be true for other areas as well,’ Dr Senior said.
‘So, for any patient who can’t afford the co-payment to see a paediatrician, essentially that means that they are unlikely to be able to afford a private prescription for fluticasone – and so they’re just blocked off from receiving that medication at all.
‘There are real health equity consequences to that where there’s the cost of seeking care and the cost of prescriptions that will prevent some people from getting appropriate treatment – and that has consequences.
‘Asthma that’s not managed well enough can be a really serious condition.’
Meanwhile, Dr Senior says even those patients who can afford to see a non-GP specialist to initiate treatment will likely have to endure a substantial wait to be seen by a paediatrician, adding to the pressure on already stretched services.
Having spoken to many of his GP colleagues and others working in the paediatric space, Dr Senior says they are all perplexed as to why the change has occurred, citing a lack of transparency from the Department of Health and Aged Care (DoH).
‘Everyone’s been saying the same things really … we’re managing this routinely and this puts significant barriers in the way of doing that,’ he said.
‘And the paediatricians I’ve spoken to say the same thing; they don’t want their lists to be filled with things that they don’t need to be managing – it’s not great use of their time either.’
Changes to the PBS listing will also impact patients who are aged over six, as they will no longer be eligible for a PBS subsidy for fluticasone propionate 50 micrograms.
‘They will be required to see their GP or primary prescriber, as they will have to switch to an alternative PBS reimbursed medicine or consider use of private prescriptions,’ the PBS website states.
‘Health practitioners can switch fluticasone propionate 50 micrograms per dose to an alternative PBS reimbursed medicine in patients aged six years and above.’ 
The DoH did not answer questions from newsGP as to why the decision to initiate patients aged six and under has been restricted to non-GP specialists. However, a spokesperson did say that the Federal Government ‘relies on the advice of the PBAC’ to make changes to the PBS.
‘The PBAC considered that patients aged six years and above would be able to switch to other PBS listed alternatives,’ the spokesperson told newsGP.
Alternative PBS reimbursed medicines with equivalent dosing to fluticasone propionate 50 micrograms twice daily for patients aged six years and above include:

  • Budesonide 100 micrograms per actuation powder for inhalation, 200 actuations (twice a day for children aged six and above)
  • Beclometasone dipropionate 50 micrograms per actuation breath activated inhalation, 200 actuations (twice a day for children aged six and above)
  • Beclometasone dipropionate 50 micrograms per actuation inhalation, 200 actuations (twice a day for children aged six and above)
  • Ciclesonide 80 micrograms per actuation inhalation, 120 actuations (once daily for children aged six and above)
While these alternatives are available under the PBS, Dr Senior notes that any change in medication comes with confusion for people and families.
The Sydney-based GP says the changes are ‘concerning’ and have come as other professions in healthcare are talking about working to the top of their scope of practice, while he says GPs’ scope appears to ‘constantly be being reduced’.
We can’t bill Medicare for reading an ECG, we have restrictions on requesting MRI scans, [we’re] being told that we can’t do mental health properly and [we have] restrictions on other medications like for ADHD and for acne,’ Dr Senior said.
‘It’s yet another restriction on practice that we would do every day and the guidelines are aimed at GPs for management – that just seems weird. And it comes in that context for general practice – that under-appreciation of the work that we actually do, which is necessary for the health system.’
While the DoH spokesperson did not give any further insight into the PBAC’s advice, which underpinned the changes, they did say that the PBAC would ‘welcome any further submissions from medicine sponsors or clinicians to make any further amendments to these PBS restrictions at any time’.
GPs can access further information on the changes via the PBS website.
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Dr Arshad Hussain Merchant   6/04/2023 4:31:33 AM

Asthma is a primary care condition & should be treated by primary care physician. Another nail in GP coffin to undermine General Practice. PBS expected parents to pay $320.00 to pediatrician to get a Fluticasone junior script. Asthma is poorly managed in secondary acre eg higher than usual doing on Salbutamol leading to severe tachycardia, creating behaviour issues, anxiety and shakes, over use of prednisolone 5mg/ml strength (steroid dependencies) = which even 1ml is equivalent to 1000mcg dose compare to 50mcg dose of Fluticasone junior deliver via spacer. So the wise board saying now in Asthma like anaphylaxis (cannot issue Epipen without paediatrician or immunologist first script), let your patient die or attend emergency department than treating and primary prevention. I am lost and cannot see the point of primary care where you are not allowed primary prevention. No more asthma action plans, no kids to daycare, childcare and schools without appropriate preventive measure

Dr Saeed Khan   6/04/2023 5:41:30 AM

It is so dumb decision that I don’t have words or energy to fight against such stupidity from our invisible alien colleagues in medicare or whatever:)

Dr Elizabeth Catherine Chappel   6/04/2023 6:21:47 AM

I rarely send a child to a paediatrician for management of their asthma . The paediatricians are overwhelmed as it is . I am intrigued by the decision making process that led to this

Dr Suresh Gareth Khirwadkar   6/04/2023 6:44:13 AM

It’s obviously to reduce the expenditure. Why else would they change it? They don’t give a toss about access or equality or equity

Dr Franklin William Butuyuyu   6/04/2023 7:21:30 AM

This to me confirms that whoever was involved with the PBAC decision in this case is completely out of touch with reality of routine patient care in this nation and their judgment in this particular case needs to be seriously questioned.

Dr Linda Rose Moss   6/04/2023 7:32:48 AM

It seem odd to me that the powers that be are constantly increasing the scope of care of untrained diagnosticians. Unfortunately, the specialist GP, when trained in diagnosis, management in multiple disciplines, having years of experience with the natural accumulation of knowledge and applied medicine that can not be learned in a book, is being told they are “ unqualified “ to prescribe . We mysteriously have lost the ability to read an ECG, diagnose asthma and more seriously show judgment as to when and what to prescribe for those conditions. It’s no wonder the community in general seems to question the ability of the GP when we seem to be given a public flogging and punished appropriately with our scope of care being reduced . Unfortunately for the health system, this shows a complete lack of foresight. We need more GP’s. We need access to our specialist colleagues when needed. Not for this rubbish.

Dr Gregory Ming Hoi Au   6/04/2023 9:01:50 AM

I had to re-read this article as I thought it was an April fool's joke.

This PBS change is truly shocking and harms the youngest and most socially disadvantaged in our community. For the pbs to save a bit on asthma medications will have a terrible human toll on children's health. It will impact our over stressed EDs beyond sight.

Obviously they did not consider it is nigh on impossible to get new referrals seen by paediatricians so parents will have to fork out more for basic essential drugs along with skyrocketing costs of living.

Dr Bradley Arthur Olsen   6/04/2023 9:59:36 AM

What a absolutely insane decision. Wow- think of the money we will save by not paying for flixotide ( federal budget ) . Perhaps these fools should think of the higher increased cost of avoidable hospital admissions and referrals to the public paediatrician ( but I guess this doesnt count as it is state budget) Resultant sum of state and federal= higher cost. Even if they dont even think about sick children

Dr Michael Lucas Bailey   6/04/2023 12:48:36 PM

If the PBS says budesonide is ok but fluticasone is not then this is clearly nothing to do with GP competence or even quality care. It is purely cost saving. Budesonide must be less expensive to the PBS than fluticasone.

Another example of cost control by red tape. Make things harder for doctors and patients and maybe they won’t bother. It’s the same approach with nearly every authority prescription.

I always wonder if the total cost is ever re-evaluated. Is it truly a saving after the cost of wasted time
by doctors and patients is accounted for? Or the lost of lost time due to mismanaged conditions or preventable complications or ED presentations for those condtions? The system cost by having doctors jump through hoops instead of treating other patients that could have prevented ED presentations? The simple cost of running the PBS authorities infrastructure to deal with inappropriate PBAC recommendations?

Dr Chiaw Lee   6/04/2023 7:59:55 PM

Has the PBAC consulted First Nations people before deciding in this crazy decision? So, a 4 year old from a remote Aboriginal community will need to travel to the city, just to get an OK for Flixotide ?

Dr Peter James Strickland   7/04/2023 11:58:31 AM

It is sad to say this has come directly from respiratory physicians, who in my opinion are the least cognisant of any physicians in pragmatic medicine. I realized the advantage of steroids some 60+ years ago when my younger brother was saved by the new"dangerous" hydrocortisone IV in 1959 whilst in a serious asthma attack as a child --it saved his life. Later the respiratory physicians stopped GPs emergency bag item of IV aminophylline (that I used innumerable times to settle and save asthma patients who over=dosed on salbutamol etc), and simply because those physicians did not use it properly and thus had side-effects ---I had none, and simply because I knew how to administer it. Inhalational steroids are needed by ALL asthmatics, and most GPs should know how to recommend it safely and effectively, and the decision should be reversed --the PBAC have blundered here again. No quick appt with a paediatrician could mean child deaths in my 60 year experience, and certainly no-pre-school.

Dr Isaac   7/04/2023 5:41:01 PM

Two points;
1- I have no words to say except we have a very weak college RACGP, doesn't give a toss for anything and has no input in any decision making by Medicare, PBAC ,TGA or whatever organisations.
2- I also blame few GPs who prescribe ICS for any child with a bit of cough or influenced by a pushy parents , and these GPs ruin the life of other doctors.

We lost the ability to claim for ECG interpretations as a results of few GPs claiming for everything just for few bucks! and I cant remember what else we have lost ....

Also I have a son who starts to study medicine but I will make every effort to make sure he does not select General Practice as career for him.

Dr Christine Colson   8/04/2023 7:47:50 PM

I'm not surprised if this decision emanates from respiratory physicians. Have you ever tried to navigate their asthma handbook? What an amazing maze it is. It's the perfect tool to wipe away anything you ever thought you knew about asthma. Nothing but an empire building tome (same species as the covid training and, to a slightly lesser extent, the immunisation handbook , bloated, repetitive, illogical).

Dr Abdul Ahad Khan   11/04/2023 4:17:57 PM

The Denudation of GPs continues whilst the RACGP Sleeps - soon GPs will be like the Emperor with his New Clothes !!!
Dr. Ahad Khan

Dr Nicola   20/04/2023 9:10:25 PM

And the reason for this change? Can’t be bothered to explain themselves ! Most likely moronic reason like most of these ridiculous restrictions .
Is to do with growth inhibition?? Well guess what , at least the growth inhibition by fluticosone is reversible unlike that of budesonide!!
Instead of putting ridiculous management blockades in place they should be concentrating if fixing the supply of basic essentials medicines. No paracetamol, amoxycillin, metformin , b12 , ozempic, penicillin , hydrocortisone , liquid children’s AB etc etc
Priority to properly manufacture essential medications here . More important that foolish limitations to GP prescribing .

Fail fail fail on every role of these pharmaceutical bodies. Sack the lot of these useless fools and put frontline GPs in place to ensure what is really needed is actually done!

Dr Nicola   20/04/2023 9:26:38 PM

And why so many ridiculous decisions from this body?
Note, NO paediatrician in the advisory but consumer/industry/ and ?3 oncologists,TWO haematolog but just one GP , despite latter is biggest prescriber group !
“Professor Andrew Wilson is the Chair of the PBAC. He has specialist professional qualifications in clinical medicine and public health medicine and a PhD in epidemiology.

Ms Jo Watson is the Deputy Chair of the PBAC. She is also the Chair of the Health Technology Assessment Consumer Consultative Committee, Deputy Chair of the Consumers Health Forum, and a long standing consumer nominee and advocate.

Ms Michelle Burke is the industry nominee. She has more than 20 years of experience in the pharmaceutical industry, contributing in areas which include access to medicines and industry development.

Professor Jonathan Craig is the Vice President and Executive Dean of the College of Medicine & Public Health at Flinders University, SA. He is also the President of the Aust