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Opinion

Why 60-day dispensing concerns are overblown


Mark Raines


10/05/2023 4:05:58 PM

Pharmacist-turned-GP Dr Mark Raines explains why he believes many of the measure’s criticisms are exaggerated.

Pharmacist with large packs of medication
Sixty-day dispensing will eventually be applied to 325 PBS medications used to treat chronic illnesses.

Come September, 60-day dispensing will become a reality.
 
The shift is expected to take place in stages, with 100 of the 325 medications initially becoming eligible, followed by a second round of additions in March next year with the remainder taking place in September 2024.
 
This means that instead of paying the monthly dispensing fee of $7.82 every month to the pharmacy, it will be paid every two months, resulting is a saving of $46.92 over 12 months for those medications.

Many medical and patient representative organisations think it is a good idea, including the RACGP, AMA, Heart Foundation, and Consumer Health Forum of Australia.
 
If you listen to Pharmacy Guild propaganda, this simple change is expected to result in the closure of countless pharmacies, loss of hundreds of jobs, further shortages of essential medication, hoarding, increased wastage of medication, and more overdoses.
 
But let’s think through some of these Guild claims.
 
Pharmacy closures and job losses
The Pharmacy Guild of Australia has conducted a financial analysis on the lost profitability and estimate $170,000 per annum will be lost.
 
However, I’m not convinced that losing $46.92 over 12 months per patient really equates to that and I doubt their workings will be made public.
 
Pharmacy makes profit on more than just dispensing. In fact, given the size of the shelves in some, I think that the front of shop provides more profit.
 
Have you ever wondered why the retail pharmacy dispensary is at the back? It’s a bit like Coles and Woolworths putting the milk against the back wall. You have to pass claustrophobia-inducing aisles of shampoo, dental treatments, toilet paper, nappies, hair dyes and vitamins before you get to the dispensary.
 
In many pharmacies you also have to walk back to the front counter to pay.
 
Of course, 60-day dispensing will mean less foot traffic which may mean less opportunity for those incidental sales. But if customers really need a hair dye, perfume or vitamin they can always make another journey.
 
Someone also suggested that pharmacies will need to buy an extra fridge and expand dispensary shelves. As far as I can tell, there is only a small number of medications on the PBS list that need to be kept cold – dulaglutide and semaglutide (which are routinely in short supply) and calcitonin and teriparatide injections (which I have never prescribed).
 
So, will retail pharmacists go broke and sack hundreds of workers as has been suggested by a number of pharmacists and the Guild? Unlikely. That is without even mentioning a clause in the Seventh Community Pharmacy Agreement which provides a safety net to these small businesses called the remuneration adjustment mechanism.
 
It was negotiated in 2020 and is set to run until 2025. I am not sure if there are any other small businesses in Australia who have a similar safety net. No adjustment was required in 2022–23 as the number of prescriptions was within 5% of estimated prescriptions.

In any case, maybe there are too many pharmacies in some areas of Australia and the economic challenge will cull those with marginal profitability?
 
Increased chance of overdose and hoarding
Sixty-day dispensing is only an option for stable and chronic medication – patients will not get 60 days of antibiotics and analgesia. Likewise, anyone who prescribes 60 days of antidepressant medication to a patient who is suicidal is likely to be in hot water.
 
I know from my previous job in a Poison Information Centre that small children do occasionally get into a grandparent’s medication cabinet. But to minimise harm, medication is already required to be supplied in a child-proof containers or blister packs, while most grandparents know to keep medication safe from small visitors.
 
Hoarding also already happens, while it is not uncommon to see medication wastage when people return unused bottles of medication no longer required.
 
The RUM Project do a great service removing unwanted medications from home medication cabinets.
 
Inevitably, there may be some increase in wastage if medication needs to be changed, but that is why 60-day dispensing applies only to stable and chronic medication.

Mark-Raines-60-day-dispensing-article.jpg
Federal Health and Aged Care Minister Mark Butler announced the adoption of 60-day dispensing last month. (Image: AAP)
 
A systematic review of extended dispensing by King, et al in 2018, did suggest there is ‘some evidence’ that longer prescriptions are associated with increased medication waste, but ‘the results were not always statistically significant and are of very low quality’.
 
There are also ways to mitigate the risk.
 
As a GP, I can look at a patient’s My Health Record and if I see 25 dispensings in 12 months, ask them why. Also, can’t this be checked at the time of dispensing?
 
Another option is to ask a patient to bring in all their tablets when I do a care plan review. When I’ve done so in the past, it is often surprising to discover the number of costly ‘complementary’ medicines a patient may also be taking. And yes, sometimes multiple boxes of the same medication.
 
Perhaps some patients should pay more for medication? It’s obviously not a popular suggestion given the patient contribution has only recently been dropped by $30, but highlighting the actual cost of medication may make patients respect its value.
 
We can also adjust our response to unused medication. To me, it seems wasteful to just throw them away. Maybe we need to rethink this strategy – after all, if a capsule or tablet is still in date and sealed in a blister pack surely it can be reused.
 
Surprisingly, some medications under the $30 threshold may already be cheaper to get as a private prescription in a 60-day or more pack size.
 
For example, Chemist Warehouse will sell 30 omeprazole for $7.99 whether you have a private or PBS prescription.
 
Medication shortages
The spectre of empty shelves has been raised. But come September, there will be no tsunami of new prescriptions when everyone comes in with a 60-day prescription.
 
And as Federal Health and Aged Care Minister Mark Butler points out, of the 325 medicines affected only seven of them are experiencing supply shortages. For an explanation as to why Australia has drug shortages this article discusses where we sit in the global pharmaceutical supply chain.
 
To help safeguard against shortages, in October 2022, the PBS introduced a Medicines Supply Security Guarantee, which requires manufacturers to hold a minimum of either four or six months’ of stock in Australia. The 60-day dispensing change may mean that this may strategy need to be tweaked, but that remains to be seen.
 
Today, I prescribed 12 acute care scripts and 16 chronic disease scripts, of which 14 would be suitable for 60-day supply, and four Webster scripts where it won’t make a difference to stock levels. That was a typical day prescribing for me.
 
Positives
Aside from the money saved on dispensing fees, patients who have a disability, don’t have access to transport or live far from a pharmacy will be grateful they don’t have to make a monthly journey for medications.
 
By reducing the daily dispensing load, pharmacists will also have a greater opportunity to do the things they have been trained for – to discuss medication with the patient and deal with the simple health problems that people visit a pharmacy for.
 
Finally, I do see some other issues, all of which are manageable:

  • Updating prescribing and dispensing programs with the new 60-day option
  • Manufacturers increasing pack sizes
  • Confusion for some patients on polypharmacy who have some medication in 30-day supplies and some in 60-day supplies
In my opinion, none of these are a roadblock to healthcare savings for those on multiple medications.
 
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