The recent announcement of 60 day dispensing intervals for prescription medications has caused major controversy, angst and outage across many pharmacists. From reading the many perspectives of this new change, it is evident the uncertainty, lack of details and projected loss of revenue can have tremendous impact to the quality and sustainability of pharmacy services. After delivering critical services during the pandemic and demonstrating exemplar accessibility, pharmacists were more stretched and exhausted from going above and beyond. But they saw a glimpse of hope emerge from years and decades of profession advocacy, as finally there was recognition that pharmacists and pharmacies are capable of doing more for the public to ease the healthcare service demands and support health promotion initiatives. Perhaps we were hopeful for a carefully staged and consultative approach to transformative change rather than a secretive handshake deal that is pushed through a top down approach. To effectively address the crippling healthcare system to address existing shortfalls and forecasted demands while at the same time ensuring quality services are maintained and health outcomes are achieved, we need to look into holistically disrupting how we fund healthcare. Building resilience and future proofing systems is required in order to survive an ever changing social, health, economic, regulatory and policy landscape. In the next few paragraphs, I will describe the unique challenges that the pharmacy industry and profession face as they manage disruptive changes and competitive pressures.
1. The community pharmacy business model heavily relies on government subsidised medication revenue to cover staff wages and the cost of sustaining a business
The 60 day dispensing interval would have probably been more well received by the pharmacy industry if there were more details on the governance and remuneration structure. It may have also been better to see how remuneration of pharmacy services such as in relation to pharmacist prescribing can also supplement revenue. However, just having this change delivered by itself leaves questions unanswered of whether this was a carefully considered decision. For instance, medication supply chain issues still persist with pervasive shortages, medication overdose and harm are exacerbated with access to larger quantities as well as stockpiling and waste issues which impact the environment. Are most pharmacies prepared and can plausibly supply 2 months of medications at a time? Can the pharmaceutical industry meet these new demands? One does wonder how this decision aligns with quality use of medicine principles that the TGA upholds with attempting to minimise pack sizes for safety reasons. Surely, one could expect that different government departments are strategically aligned with changes, particularly mapping downstream impacts. However, the development of this new policy and the arrival to the final solution has been a hush secret without much explanations. Over the years, I have observed that the pharmacy business model is quite vulnerable and despite the ability to compete in the private market that can be quite a challenge for a small business player. The way in which pharmacies have been funded is through the remuneration of a product, the medication, which in turn funds wages and expenses. Many pharmacies expand into health and wellness product ranges, which they are competing with publicly listed companies such as supermarkets and larger players with high scale bargaining power that can set competitive prices. Therefore, for the smaller pharmacy with modest margins, their core competency of prescription medication dispensing that is predominantly sustaining their existence is supported by the government. As cost of living expenses rise for the average person, understandably this change could lower the cost of medicines in line with other products and goods in other industries. When consumers purchase medications from a pharmacy they see the product they get and not realising they are paying for the service and sustenance of a thriving pharmacy. So what about trying to make people pay for pharmacy services instead of just relying on government funding? Well, there are few people out there who would think they would benefit from a review of their medications and advise their doctors accordingly. I do not believe people are ready to believe that their doctors are human and imperfect to the extent where they feel compelled to organise an independent review of their medication regimen for optimisation. Neither do many understand that while individually, doctors and specialists can act with the best intentions with prescribing within their scope of speciality, the pharmacist strives to harmonise, synergise and optimise medication regimens. This is so that patients holistically can get the most out of their medications with increased efficacy, reduced risk and reduced waste. Additionally, many of medication reviews and interventions performed are usually with people who may not be aware they can benefit from one or who can afford to pay for one. Any other forms of services that pharmacies would want to introduce would require people with specialised skillsets and high volumes to make a margin. In a heavily regulated industry, it can be a challenge to be innovative and strengthen capabilities to have more than one robust revenue stream. It is important that the cumulative changes to PBS remuneration do not leave more pharmacies worse off and bankrupt over time. Healthcare sustainability should be addressed with wider industry consultation and impact modelling to ensure changes meet their intended benefits.
2. The resiliency of humans within the pharmacy industry
Whenever there have been major announcements to government PBS remuneration for pharmacies such as the $1 discount and reduction in price disclosure cycle, pharmacists have shown backlash and have been vocal on the consequences. Yet still the change goes ahead, life goes on, the cost cutting measures begin and the incremental impacts are felt over time. I remember the first time experiencing a price disclosure cycle reduction change back in my uni days where it was explained that it could lead to cuts to pharmacy student hours or the reduced ability to offer pharmacy intern positions. I remember a pharmacist explaining to me that stock on the shelf would be remunerated differently today, compared to the next day when price disclosure comes into play. I remember being on placements where the $1 discount was also being implemented close to the same time a price disclosure was kicking in. A pharmacist recounted that they had no stock of an expensive diabetes medication and faced a challenging dilemma. Ordering the medication right before price disclosure would lead to a loss in revenue but ordering it the next day would lead to a delay in stock for the patient. Luckily they rung different pharmacies and were able to obtain stock. The humans within pharmacies act in service of others who together can weather out storms, adversities and hardships. As pillars within communities and in particular in times of crises, pharmacies have gone out of their way to assist with continuity of care and consistent referrals of people to appropriate services. I have full confidence that some pharmacies will make it work with the new 60 day interval change but potentially for some other pharmacies it could be the last straw or the final nail in the coffin. If that is a rural pharmacy, it would send further shockwaves through the community and further impact accessibility to care. Just like with small businesses who were unable to recover from successive covid pandemic lockdowns, interest rate hikes, utilities rate increases, cost of living rate increases and wage increases, it shows that resilience can go a long way but not everyone can have the means to continue surviving. With stagnant wages, increasing workloads and KPIs to make up for the loss of revenue, it is understandable why there is a shortage and exodus of pharmacists and pharmacy assistants. With the strive for work life balance and better work conditions, resilience can often take the form of doing what is best for the self to be in a better position to give to others in whatever way we can.
3. Why the role of pharmacy practice is worth fighting for and why it is often misunderstood
Pharmacy practice is heavily centred on governance, harm prevention and risk management. If you imagine the indignant attitude that is directed towards paying for high cost items, that would be the same type of attitude expressed towards experiencing harm from taking the wrong medication. Who was there to prevent it from happening in the first place? Unfortunately, there is often more adulation and emphasis for those who fulfil a need when we need it rather than appreciation for those who do their job well to prevent us from suffering harm. That means that while pharmacists and staff are busy serving the community and public, they may not have the capacity to explain what they do in a job that seemingly appears like the repetitively manual role of sticking labels on boxes. Therefore it is a challenge to also serve the public while at the same time invest in consistently promoting the job and outcomes we achieve at a political level. As mentioned before, a pharmacists wage is predominately remunerated based on the cost of the product sold so therefore the time spent on intervening harm, liaising with doctors to clarify prescribing intentions and educating patients on medication safety is absorbed in that cost. Not to mention, a customer can easily walk into a pharmacy for advice and choose not to buy any products. Luckily, I believe many customers do value their local pharmacy and would continue supporting them while they can. There are those who understand, those who strive to understand and those who only come to understand our role when they need us. I hope that moment does not come too late because medicines are great for health and wellbeing when they are used appropriately and safely. Your pharmacist can only do their job and give as much to their people as long as they are well supported and not under tremendous pressure to sustain the pharmacy business to keep them there. Every change has a reaction and this time pharmacists have responded in the pursuit to protect pharmacy practice and to minimise the devaluing of the profession and the industry. There are different ways to approach the issues of spiralling cost expenditure in healthcare and all that pharmacists ask is that they are included in these critical discussions. Never before have I seen a wave of pharmacists and prominent leaders leveraging social media platforms to voice their grave concerns, bewildered incredulity and immense shock at this 60 day dispensing interval proposal. While I believe there is a minuscule chance and yet another small glimmer of hope that the proposal can be overturned based on people power and a grass root movement, it is endearing to be reminded that a fighting spirit exists within the pharmacy industry. Sadly when you are talking about addressing the scale of big large hairy problems like limited funding for a buckling healthcare system, what we feel can easily get lost in oblivion in the perceived greater good of crunching numbers with savings redirected elsewhere. Regardless of the outcome, we can only hope that lessons are learnt with consultation practices because with limited resources, we cannot afford for more policies to be implemented that are quick wins that do not effectively benefit people in the long term.
Healthcare & Pharmacy Musings 