CHAPTER 3
EXEMPTION FROM PAYMENT OF THERAPEUTIC GROUP PREMIUMS
3.1
As outlined in Chapter 1, drugs in a therapeutic group may be subject to
a charge in addition to the co-payment amount, known as a 'therapeutic group
premium'.[1]
This additional fee is paid by the consumer and only applies to a medicine
where the manufacturer does not accept the Pharmaceutical Benefits Scheme (PBS)
price under the therapeutic group pricing policy.[2]
3.2
At present, there are 523 brands of medicines in therapeutic groups. Of
those, six have a therapeutic group premium applied ranging in value from $2 to
$4.35.[3]
3.3
When prescribing a medicine subject to a therapeutic group premium, a
doctor may apply for a patient to be exempt from paying the premium on the basis
that it would be 'clinically inappropriate for a patient to be prescribed a
different medicine in the therapeutic group in order to avoid a therapeutic
group premium'.[4]
In this circumstance, the Commonwealth Government pays the patient premium
where the prescriber has obtained an authority from Medicare Australia, based
on one of the following specified criteria:
- the patient suffers from adverse effects when taking all of the
drugs in the group that have no therapeutic group patient premium;
- the patient experiences drug interaction issues when taking all
of the drugs in the group that have no therapeutic group patient premium;
- it is expected that the patient would experience drug interaction
issues if they took any of the drugs in the group that have no therapeutic
group patient premium; or
-
transferring the patient to a drug in the therapeutic group that
has no therapeutic group premium would cause patient confusion resulting in
problems with compliance.[5]
3.4
During the course of the inquiry, a number of doctors suggested to the
committee that oral bisphosphonates were not interchangeable at a patient level
on the basis of:
...clinically significant differences in these agents in terms
of their speed of onset and persistence of effect at offset. There are areas
where there are distinctly different levels of evidence on efficacy, e.g.
corticosteroid osteoporosis treatment, between the different agents. Moreover
there are differences that may relate to compliance as to whether they can be administered
weekly, monthly or annually.[6]
3.5
As a result of these clinical differences between the oral
bisphosphonates, doctors in the field were concerned that the creation of a
therapeutic group for the bisphosphonates might result in 'patients suffering
financial or therapeutic penalty'.[7]
3.6
It became apparent to the committee that some of these doctors were
unaware that they were able to request on exemption on behalf of their patients,
so as to avoid any financial or therapeutic disadvantage. Dr Gabor Major stated
he 'certainly was not aware...that we can ring up and request a special
dispensation for the patient'.[8]
Professor Stephen Oakley and Dr Charles Inderjeeth were equally unaware of the
exemptions.[9]
3.7
The department advised that a two-year education campaign was carried
out, commencing in 1997-98, to inform prescribers of the introduction and
implications of the therapeutic group policy:
The education campaign included:
- Direct mailings to prescribers of
PBS medicines;
- A telephone help line service;
- A health professionals and
consumer groups information kit;
- Consumer leaflets for distribution
by medical practices and pharmacies;
- Articles in the Health Insurance
Commission (now Medicare Australia) Forum and other professional and consumer
group newsletters; and
-
An insert in the Schedule of
Pharmaceutical Benefits, which at the time, was distributed free-of charge to
doctors at each update.[10]
3.8
The committee is concerned that doctors responsible for prescribing
medicines in therapeutic groups may be unaware that they are able to seek an
exemption from a therapeutic group premium on behalf of their patients. The
exemptions are intended to protect patients from additional costs, in cases
where medicines in a therapeutic group are not interchangeable at the individual
patient level. However, the exemptions cannot achieve this if those responsible
for prescribing medicines that attract a therapeutic group premium are unaware
of the exemptions.
3.9
The committee acknowledges the work undertaken by the department to
educate prescribers at the time the therapeutic group policy was first
introduced during 1997-98. The committee believes, however, that regular and
ongoing education and information is required to ensure prescribers are aware
of the exemptions from payment of a brand premium and the process for seeking
those exemptions on behalf of a patient via a Medicare authority.
Recommendation 3
3.10
The committee recommends that the Department of Health and Ageing
provide regular and ongoing education and information to prescribers to ensure
they are aware of the exemptions from payment of a brand premium and the
process for seeking those exemptions on behalf of a patient.
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