Issue 12 / 8 April 2013

THERE is growing evidence that medication compliance is a predictor of better health for many reasons.

But making it “easy” for patients to access their medications and providing the right medication are the keys to success. While a Cochrane summary showed overall compliance of about 50%, one study showed that only 13% of patients with type 2 diabetes were taking their oral medications 90% or more of the time, which is considered “adequate” compliance.

As an Australian general physician who practised in rural/regional Australia for 8 years, and who has also practised for many years in the US and more recently in Canada, I believe that Australia has the best health care system. I was particularly grateful for the Australian Pharmaceutical Benefits Scheme (PBS) every time I took care of patients.

I have prescribed PBS Authority drugs on hundreds of occasions, frankly with few delays or hitches.

Interestingly, I was turned down only once for an authority script, for a patient with hyperaldosteronism (with malignant hypertension) who had a severe allergy to spironolactone. The other very specific treatment, eplerenone, was only approved for heart failure.

Despite calls and letters, the PBS system was impenetrable and the hospital ended up paying for the medication in order to prevent multiple costly emergency department visits. As a result, the patient had no further ED visits, saving tens of thousands of dollars.

But for most cases, dealing with the PBS just took time on the phone — time to ask for what was nearly always approved. The introduction of the “streamlined” authority, with which some items no longer require telephone approval, was particularly helpful.

For doctors, the time saved through streamlining could be spent discussing the rationale for medications with patients and answering their questions. There is evidence that this actually works. For example, data from diabetes patients shows that patients of doctors with higher empathy scores have better outcomes, probably because those doctors help them understand the need for regular bothersome medication regimens and make it easy for them to get their medications.

In the US health care system, estimates are that health insurance and prescription authorisations (with health insurance companies, etc) take up about half a day (one session) per week for primary care providers, at a cost of more than US$60 000 per physician per year. PBS authority doesn’t take nearly that amount of time, but simplifying the system could produce cost savings.

The best way to improve the system is to help doctors with difficult prescribing decisions. I agree with MJA InSight columnist Dr Aniello Iannuzzi that sometimes doctors need expert pharmacists to provide advice when accessing the PBS, as happens with the Department of Veteran Affairs. I think it should go further, with expert physicians “on-call” too.

Using the example of my patient with hyperaldosteronism, having an opportunity to discuss the clinical dilemma with an expert who truly understood the issue might have resulted in the medication being approved, saving a lot of time for me and others.

Despite the artificial federal–state split in money spent on health in Australia the cost comes out of every taxpayer’s pocket — so any moves to save time benefit me, my patients, society in general and the health system.

Every time I look at the worldwide statistics on health care outcomes and relative costs, I’m proud to call Australia “home”. However, we can still make our world-class PBS Authority system even better, while maintaining accountability around prescribing and medication costs.

I suspect that cost savings from streamlining could be substantial, so why isn’t some of that money redirected towards providing help to doctors with difficult prescribing questions, thus educating them and improving medication compliance?

Professor Dawn DeWitt is an honorary professor at the Rural Health Academic Centre, University of Melbourne Medical School, and professor of medicine and associate dean of Undergraduate Medical Education in the Faculty of Medicine, University of British Columbia, Canada.

Posted 8 April 2013

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