‘The bane of my life’: Authority approvals under scrutiny

Dr Rob Hosking does not mince his words about authority approvals. 
 
‘Incredibly frustrating,’ he told newsGP when discussing the push to improve the unloved sign-off system for prescribing restricted medications.
 
The Chair of the RACGP – Practice and Technology Management Expert Committee, Dr Hosking is at pains to stress his pride in the Pharmaceutical Benefits System (PBS).
 
‘It is providing medicines at a much-reduced cost to the public compared with other countries, and we should be celebrating that,’ he said.
 
‘We also need to look at the inefficiencies that have developed over the years in the system and see whether we can improve.’
 
And it is this latter part of his role, working to encourage a more efficient system for prescribers and patients, that is the source of much of Dr Hosking’s exasperation.
 
‘It’s frustrating for every GP, multiple times a day,’ he said.
 
‘But it’s frustrating for me as the Chair because we keep having improvements put forward, but they keep getting blocked by a lack of willingness to develop and fund them properly.’
 
Managed by Services Australia, applications for authority approvals are now made for almost 7 million medications each year. Most, historically, have been via phone, some online, while others, more rarely, on paper or via prescriber software.
 
A newsGP poll last September suggested Dr Hosking is far from alone in his view of how it is working. It found around one in three respondents rank authority approvals as their ‘greatest administrative burden’. Only WorkCover claims got more votes – by a fraction.
 
The Audit Office’s report on the PBS
An Australian National Audit Office (ANAO) report into the administration of the PBS, released late last year, gives perhaps the clearest official picture yet into why frustration is rising among GPs.
 
It includes a snapshot of a service agreement between Services Australia and the Department of Health and Aged Care (DoHAC), showing Services Australia has failed to meet a 30-second average target to answer approval calls every month since the agreement began in 2022.
 
In fact, by December 2023 wait times had peaked to more than 160 seconds on average, more than five times longer than the target.
 
‘The timeliness of authority approvals impacts doctors and other PBS prescribers who need to seek authority approvals, often during a consultation with a patient,’ the ANAO report drily noted.
 
One GP commenting on newsGP was more colourful, describing authority scripts as ‘the bane of my life’.
 
‘If doing it by phone, we first have to endure the same 20-second voicemail message every time,’ they wrote.
 
And could it be worse than those statistics suggest? ANAO notes when counting phone calls and their duration, the Services Australia telephone management system recognises a call as complete after it transfers.
 
‘This means that a single phone call from the perspective of a caller may be counted as two or more separate phone calls for performance monitoring purposes, each with a separate answer time,’ the ANAO states.
 
‘The [service agreement] measure does not account for this.’
 
Services Australia, meanwhile, point to improvements since the ANAO report was researched, with a spokesperson saying that extra staffing put in place due to COVID-19 had helped to alleviate the pressures the department was under.
 
Following the introduction of 3000 more service delivery staff from late 2023, they say claims processing times and backlogs ‘have improved significantly’.
 
From July to December 2024, they note, the average time to answer was 65 seconds, 32 seconds swifter than the average for the previous financial year.
 
However, Services Australia also rejected a recommendation within the ANAO report to include the timeliness of issuing authority approvals within 30 seconds in its annual performance statement, saying it had an existing 15-minute target across all operations.
 
‘Aligning this measure with targets agreed in bilateral arrangements is not possible as the measure includes customers served across all Services Australia’s programs,’ it told the ANAO.
 
The rise in online PBS authorities
Given the context, it is perhaps also unsurprising the ANAO records a surge of GPs no longer picking up the phone but heading instead to Online PBS Authorities (OPA), which is accessed via Health Professionals Online Services (HPOS).
 
At the start of the 2022–23 financial year, more than 70% of authority applications were by phone. By the end of 2023–24, that fell to 54.5%, with more than 40% going via HPOS. That number has reportedly increased further still since.
 
Dr Emil Djakic, a member of the RACGP Expert Committee – Funding and Health System Reform, says only half-jokingly that he began using HPOS for authority approvals around three years ago because he couldn’t stand listening to the hold music.
 
Even so, he is hardly enamoured.
 
‘Patients sit here and regularly comment and laugh at what I’m doing,’ he told newsGP.
 
‘They laugh in a satirical way. They just can’t believe that this is what their doctor’s being asked to do, which is effectively be a call centre operator.
 
‘The data that I’m supplying is exactly the same data I would give verbally to the call centre operator to enter into their system at their end.’
 
The system has been notorious for its lack of user-friendliness, with prescribers unable to copy and paste basic information – including a patient’s Medicare number – or save details when patients require more than one authority request.
 
‘We have to get authority approval every time we prescribe, even though I’ve got patients who’ve been on the same drug for 10 years, they still have to come in and I have to go through the process again,’ Dr Hosking said.
 
Another GP counted an average of 80 clicks and keystrokes to log in, enter Medicare details, drug name, and script number before seeking approval.
 
The ANAO also highlights another issue created by the shift online. It reveals that authority applications via HPOS are rejected at more than twice the rate (5.6%) compared to the phone (2.3%).
 
‘Multiple authority codes for single medicines create confusing administrative burdens for prescribers,’ Dr Djakic said.
 
‘It’s a huge problem when you’re looking at a screen online and seeing multiple codes, but no ability to view the descriptor to see which to pick.’
 
Services Australia, meanwhile, says for the number of applications the rejection rate remains low. In response to a newsGP inquiry, a spokesperson explained that phone staff ‘may pick up where prescriber errors would result in a rejection’.
 
However, it did not specify any measures in place to lower the online rejection rate.
 
Solutions put forward
Previous RACGP advocacy has led to work addressing ‘pain points’ of the process and Dr Hosking does acknowledge some improvements.
 
‘The HPOS system is better than it was a year ago, but there’s still a lack of integration with GP prescribing software, or any prescribing software,’ he said.
 
As Dr Hosking has written, detailed solutions have been suggested. Emma Hossack, the Chief Executive of the Medical Software Industry Association (MSIA), said her organisation has proposed a way to integrate OPA with clinical software, which currently accounts for a fraction of the authority applications.
 
Ms Hossack understands the flaws of the system, and the way GPs feel about obtaining authorities.
 
‘It is unfair to put the impost of poor admin onto one of the most precious resources, i.e. GPs,’ she told newsGP.
 
‘The current process for OPA is inefficient, deterring even the most digitally savvy GPs from adoption.
 
‘The result is frustration, long waits, and the expense of running call centres.’
 
Ms Hossack says the association’s proposal would help streamline the process and give greater transparency to Government about what medications are being used where.
 
It would also use the Fast Healthcare Interoperability Resources (FHIR) standard backed by the DoHAC and the Australian Digital Health Agency.
 
However, in its own submission to the ANAO, the MSIA noted ‘a clear desire to continue using the existing system and making modifications which will amount to no more than lipstick on a pig’.
 
‘The attitude is disappointing,’ it said. ‘The proposition for improving online prescription authorities is supported by the AMA and RACGP and is technically feasible and efficient.’
 
Its proposal has not progressed.
 
Ongoing admin burden
In its response to newsGP inquiries, Services Australia says the OPA system has been developed ‘to support integration with clinical software’, and that it recently published updated PBS Authority Application Programming Interfaces (API) for prescriber software developers.
 
Ms Hossack makes the point that Services Australia has supplied a non-standard API instead of FHIR, making it harder for MSIA members.
 
‘Industry has to keep spending resources redoing integration,’ she said.

It has also done little to shift Dr Hosking’s view on the pace of change.
 
The most recent RACGP Health of the Nation report suggests that admin burden is one of the principal reasons GPs leave the profession, and he fears without significant action the authority approvals process will continue to be a factor.
 
‘We meet with [the DoHAC and Services Australia] regularly on various topics, and [authority approvals] is one that comes up virtually every time,’ Dr Hosking said.
 
‘There’s a big bureaucratic burden on GPs for various things. When they seem unnecessary nonsense, you just get so cross, and you get people saying, “well, I’m going to give up and go and work in a different system”.
 
‘It’s an ongoing issue.’

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