Information for Clinicians and Hospital staff

Patient Information Brochure (pdf, 202kb)

The Pharmaceutical Reforms comprise 3 main elements:

• Access to the PBS for all public admitted patients on discharge and non-admitted patients. Patients will be able to get up to one-month's supply (or clinically appropriate supply of up to one month) of medication.
  - More Details
• Access to a list of chemotherapy drugs subsidised by the Commonwealth Government. These chemotherapy drugs will be available to day patients and outpatients - More Detail
• Implementation of the Australian Pharmaceutical Advisory Council guidelines on the continuum of pharmaceutical care. - More Details

Under the new scheme, hospitals will be able to prescribe PBS medication to all non-admitted patients and patients on discharge, and will provide up to one-month's (or clinically appropriate) supply of pharmaceuticals. These medications will be able to be dispensed at the hospital pharmacy or at a community pharmacy.

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Co-Payments

Under the National Health Act 1953, collection of a patient co-payment is required whenever a PBS prescription is dispensed. The amount of the co-payment will be different for general and concession patients ($32.90 and $5.30, respectively). At present, most public hospitals collect payments for pharmaceuticals dispensed to outpatients so there will be minimal change. However, most hospitals do not charge patients at discharge, as only a few days medication is usually provided.

The collection of a co-payment is the same practice as in the community where a charge is levied whenever a prescription is dispensed. Essentially, the payment of the co-payment is being brought forward by a couple of days from the community to the hospital.

The benefits are that patients will be able to visit their local doctor for their first post-hospital visit when it is convenient and appropriate for them, and not for the sole purpose of obtaining more medication. It also means that hospital paperwork, such as the discharge summary, should have reached a patient's usual doctor before they present for their first visit, thereby keeping the community doctor better informed and improving the patient's overall level of care.

How do we go about collecting co-payments from patients?

Ideally, arrangements will need to be made for patients to be able to pay at multiple locations by credit card, cheque or cash, or to be sent an account.

Collection of co-payments is the responsibility of the individual hospital. Hospitals are under no obligation to collect a co-payment, however, the hospital will be reimbursed at the PBS price minus the co-payment.

DHS and Medicare Australia will provide hospitals with consumer information brochures and posters.

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Who is eligible for concession payments?

Patients eligible for concession are holders of a Pensioner Concession Card, a Commonwealth Seniors Health Card, a Health Care Card, a Repatriation Health Card for All Conditions, a Repatriation Health Card for Specific Conditions or a British, Commonwealth and Allied Veterans (BCAL) card.

Patients eligible for concession pay $5.30 towards each prescription, up to a maximum total of $318.00 in the calendar year, after which there is no charge for the remainder of the year.




What happens to patients who don't meet the PBS requirements?

Where a PBS listed drug is prescribed outside the PBS requirements, Medicare Australia will not reimburse the cost of the drug and this will have to be fully funded by hospitals. Hospital prescription forms will contain a tick box for the doctor to declare that the patient's condition meets PBS/RPBS requirements.

Waiving the patient co-payment

Co-payments may be waived for particular patients at the discretion of the hospital, however the hospital will be reimbursed by Medicare Australia at the ex-manufacturer price plus 11.1%, minus the co-payment. No top-up funding will be provided by DHS when hospitals choose to waive co-payments.

Please note that pharmaceuticals that attract a Brand Price Premium, Therapeutic Premium or a Special Patient Contribution (SPC), will incur a charge additional to the co-payment.

Safety Net

The Joint Safety Net Scheme will continue to operate in hospitals. This means both PBS and non-PBS items (up to the amount of the applicable co-payment) can be added to a Safety Net Card. Outside the hospital only PBS items can be added to the Safety Net Card. Therefore, there may be financial advantages for patients to get their medication dispensed within the hospital.

The Safety Net Scheme exists to protect patients or their families who spend a lot on medications in a calendar year. Once a patient or their family reach the Safety Net threshold they can apply for a Safety Net Card.

A family can include:

• A spouse or de facto spouse
• Children under 16 in adult care; and
• Full time dependent students under 25

General Patients: When a patient or their family has a record of spending $1264.90 on PBS medications and non-PBS medications from hospitals in a calendar year, they are entitled to further medicines at $5.30 for the remainder of that year.

Concession Card holders: When a concession patient or their family have a record of spending $318.00 on PBS medicines and non-PBS medications from hospital in a calendar year, they are entitled to further PBS medicines free for the remainder of the calendar year.

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Prescriptions

Writing and dispensing of PBS prescriptions will be a new task for some staff. Prescription forms need to be written and dispensed accurately in all cases, otherwise the claim will not be processed for reimbursement by Medicare Australia. Training and education programs will take place in all public hospitals where PBS prescriptions will be written, even if there is no pharmacy dispensary on site.

A new prescription form has been designed specifically for public hospitals wishing to access the PBS reforms.

A hospital identifier number will be pre-printed on each prescription. This allows every prescription to be linked to a particular hospital. Hospital PBS prescriptions can only be written by doctors, dentists and endorsed optometrists employed by that hospital and for patients seen at the hospital.

All prescribers must attend a training session run by the Medicare Australia in order to obtain a Prescriber number.

Will prescribers have to ring up for approval to prescribe authority drugs?

Yes. Any drugs which are currently listed as authority items will require a telephone approval through Medicare Australia.

For PBS authority, phone 1800 888 333
For RPBS authority, phone 1800 552 580

Victoria has asked the Commonwealth to ensure that all telephone operators are aware of special hospital requirements to make the process as smooth as possible.

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Implementing these reforms will mean that our Pharmacy IT systems will need upgrading. Is there any assistance available for this?

Victoria has provided additional money to all Victorian hospitals with a pharmacy department so they can purchase or upgrade to the required software.

Dispensing

Hospitals are not obliged to dispense PBS items and may elect to send patients to a community pharmacy. However, in these circumstances the prescription will still be attributed to the hospitals associated ceiling level. Hospital prescriptions dispensed in the community include professional fees, which Medicare Australia will also contribute towards the hospital's ceiling level.

Small and rural hospitals may find it viable to send most or all patients to community pharmacies for dispensing. Metropolitan hospitals might also find it convenient to send patients to their local pharmacy for dispensing on weekends and after hours.

Please note that under the National Health Act 1953 public hospital pharmacies are prevented from dispensing PBS prescriptions that originate in the community. Hospitals are able to dispense hospital PBS prescriptions that originate from another participating hospital.

Will we have to stock the full range of PBS items?

No, the hospital formulary will still be determined by each hospital's Drug Committee (or equivalent). It is recommended that hospitals examine their existing formulary carefully and decide which drugs could be replaced by PBS items in order to gain the maximum benefit from these reforms.

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Will an outpatient prescription written in one hospital be able to be dispensed in the patient's local country hospital?

A hospital PBS prescription can be dispensed by any community pharmacy or any other hospital participating in pharmaceutical reforms. Non-participating hospitals cannot dispense PBS prescriptions.

Claiming

Claiming is by CTS disk and the prescription form, as standard in community pharmacies. Hospitals will be able to claim reimbursement directly from Medicare Australia for PBS items dispensed to outpatients and patients on discharge. Medicare Australia accept claims on a fortnightly or monthly basis. The price claimed for dispensing PBS items, other than cytotoxic chemotherapy drugs listed under s100, is the price ex-manufacturer plus an 11.1% mark up, minus the patient co-payment.

If a prescription is rejected for payment by Medicare Australia due to insufficient or incorrect information, it will be returned to the hospital pharmacy to correct and re-submit.

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PBS Funding Ceilings

Each public hospital will be allocated and advised of their PBS funding ceiling. If the limit is reached Medicare Australia will continue to make payments but 50% of the amount over the threshold will need to be recouped from hospitals, as agreed under the risk sharing arrangements with the Commonwealth.

All hospitals will be provided with cumulative summaries of the total costs attributed to them. It should be noted that only the Commonwealth component of the PBS cost will count towards the budget, it does not include the patient co-payment. All PBS prescriptions written in a public hospital will be recorded as expenditure from that hospital, even if they are dispensed in a community pharmacy.

Will Victoria change the existing funding arrangements?

No, the Department recognises that hospitals will still need to meet the cost of non-PBS drugs, co-payments for day-admitted chemotherapy patients, and that not all hospitals across the State are participating, therefore DHS has decided not to alter the current funding arrangements at this stage.

Supply of Equivalent Amounts of PBS and Non-PBS Items

Participating hospitals will be required to supply equivalent amounts of non-PBS items (up to 30 days if clinically appropriate) to non-admitted patients and patients on discharge. Non-PBS items will continue to be supplied out of the pharmacy budget, however hospitals may charge patients up to the cost price of the drug.

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Access to chemotherapy drugs under Section 100 - Chemotherapy Pharmaceuticals Access Program (CPAP).

A range of chemotherapy drugs will be dual-listed under the provisions of Section 100 of the National Health Act and funded by the Commonwealth for use by day and non-admitted public hospital patients in participating hospitals.

Pharmaceuticals available under this program are listed in the 'Chemotherapy Pharmaceuticals Access Program Supplement' to the Pharmaceutical Benefits Schedule. The Supplement is available to participating public hospitals and on this web site.

Hospitals providing oncology services will be assigned a ceiling cap for chemotherapy drugs in addition to their PBS ceiling cap. The Commonwealth, through Medicare Australia, will reimburse the full cost of these drugs at the ex-manufacturer price less the applicable patient co-payment.

Under the new risk-sharing arrangements the Commonwealth will share the cost of drugs above the threshold. In practical terms, this means that Medicare Australia will continue to make payments but 50% of the amount over the threshold will need to be recouped by DHS to reimburse the Commonwealth.

Schedule of Pharmaceutical Benefits - Chemotherapy Pharmaceuticals Access Program (See downloads at the top of this page)

Will chemotherapy patients have to pay co-payments for their cytotoxic drugs?

Not if they receive them while they are a day-admitted patient. Under the terms of the Australian Health Care Agreement admitted patients cannot be charged for services or pharmaceuticals.

Chemotherapy patients can be charged co-payments for medicines dispensed on discharge or received as an outpatient.

Co-payments for chemotherapy drugs will be charged to patients at levels equivalent to the PBS. Hospitals have discretion to waive collection of co-payments from their patients, but they will still be deducted from Medicare Australia.

Authority-required drugs

Pharmaceuticals available in this section are dual listed within the Pharmaceutical Benefits Schedule and the same set of conditions for prescribing will apply. This means that some drugs require prior authority approval from Medicare Australia before they are dispensed, some are restricted benefits and some are available without an authority.

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Implementation of APAC's Guidelines on Quality Use of Medicines

The Commonwealth and State steering group on pharmaceutical reform have negotiated a set of milestones for the implementation of the Australian Pharmaceutical Advisory Council's guidelines for the continuum of quality use of medicines between hospital and the community. The seven principles are:

• Development and coordination of a medication discharge plan for each patient;
• Taking an accurate medical history;
• Evaluation of current medication by hospital staff on admission;
• Development of a treatment and discharge plan relating to the probable medication developed in consultation with the patient and/or carer;
• Pre-discharge medication review;
• Provision of information to the primary health care provider and carers, and;
• Provision of patient information regarding admission, medication changes and arrangements for follow-up to the health care provider(s) nominated by the patient.

Completion of the milestones is staggered over a three year period from the time a hospital starts to access the reforms.

Principles to ensure the continuum of pharmaceutical care between the hospital and the community (PDF File 333KB)

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How will the Commonwealth know if we are implementing the APAC guidelines?

As part of Victoria's Agreement with the Commonwealth, DHS will be required to submit annual reports to the Commonwealth which guarantee that Victoria has appropriate documentation from each participating hospital. Periodically, DHS will require hospitals to provide information on how they are meeting the milestones.


How do we obtain a Medicare number for a patient that has forgotten to bring their card with them to hospital?

There is a Hotline set up for hospitals to telephone when they require a Medicare number for a patient. Alternatively, hospitals can fax Medicare Australia groups of patients requiring Medicare numbers. The Hotline number is:

1300 302 122

 

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