How to improve Indigenous patients’ access to medicines

We’ve been hearing plenty of outrage in recent weeks over delays to the listing of new medicines on the Pharmaceutical Benefits Scheme (PBS). One issue which may not have attracted the public outrage that it merits over the years has been the differential access of Aboriginal and Torres Strait Islander people to PBS medicines. It […]

We’ve been hearing plenty of outrage in recent weeks over delays to the listing of new medicines on the Pharmaceutical Benefits Scheme (PBS).

One issue which may not have attracted the public outrage that it merits over the years has been the differential access of Aboriginal and Torres Strait Islander people to PBS medicines. It is yet another example of the enduring relevance of the inverse care law, first described in the UK in 1971.

However, efforts are underway to improve the access of Indigenous patients to PBS medicines, and it is important that general practices and their patients know about these.

The initiatives are outlined by Dr Noel Hayman, Clinical director of the Inala Indigenous Health Service in Queensland, in an article (PDF alert) just published by Australian Prescriber.

I am grateful to Australian Prescriber’s editor Dr John Dowden for allowing re-publication here for Croakey readers.

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Improving Aboriginal and Torres Strait Islander people’s access to the PBS

By Dr Noel Hayman

Summary

Despite having greater morbidity and mortality than other Australians, Aboriginal and Torres Strait Islander people underuse the Pharmaceutical Benefits Scheme. Increasing their access to medicines could improve their health. To improve access, there are some specific medicines on the Pharmaceutical Benefits Scheme for Aboriginal and Torres Strait Islander people. There is also the Indigenous Chronic Disease Package which will assist with the cost of medicines. Incentives are being provided for doctors to enrol their Aboriginal and Torres Strait Islander patients to obtain these benefits.

Introduction

Aboriginal and Torres Strait Islander people suffer from the burden of chronic disease at a rate 2.5 times that of other Australians, with approximately one-third of the burden due to vascular diseases.1

Cardiovascular disease, chronic kidney disease and diabetes are the main problems and share the common risk factors of smoking, high blood pressure, high cholesterol, physical inactivity, obesity and a low intake of fresh fruit and vegetables.1

This increase in the burden of chronic disease should be reflected in an increase in the prescription of drugs for the treatment of heart disease, diabetes, chronic kidney disease, mental health and lung conditions.

However, data from the Pharmaceutical Benefits Scheme (PBS) show that Aboriginal and Torres Strait Islander people access the PBS at a lower rate than other Australians.2 Indigenous people also underuse primary healthcare consultations and specialist care.2

PBS drugs specifically for Aboriginal and Torres Strait Islander people

In 2005 a committee was established by the Commonwealth Department of Health and Ageing to provide advice on ways to improve the capacity of the PBS to meet the health needs of Aboriginal and Torres Strait Islander people.

The Pharmaceutical Benefits Advisory Committee recommended that from 1 August 2006, 15 medications be listed on the PBS to treat common fungal skin conditions, chronic suppurative ear conditions and vitamin B₁(thiamine) deficiency. Table 1 shows the current drugs available as authority prescriptions on the PBS specifically for Aboriginal and Torres Strait Islander people.3

The rationale for subsidising these drugs is the higher rate of disease seen in the Aboriginal and Torres Strait Islander population compared to the non-indigenous population. Indigenous people suffer higher rates of chronic suppurative otitis media (particularly children4,5), have higher rates of fungal infections,6 are more likely to drink alcohol at harmful levels (thiamine prophylaxis),7 have smoking rates 2-3 times higher than other Australians (nicotine replacement therapy)8 and have higher rates of whipworm, strongyloidiasis and hookworm (albendazole).9

General practitioners working in Aboriginal and Torres Strait Islander Community Controlled Health Services are very much aware of this initiative and regularly prescribe these drugs for the benefit of their patients. However, many Aboriginal and Torres Strait Islander people access mainstream general practice where some doctors may be unaware of this important initiative for improving their access to these drugs.

Affordability of drugs

The price of medicines is a major barrier for Aboriginal and Torres Strait Islander people filling their prescriptions. Past Commonwealth inquiries have shown that despite them having higher morbidity than the non-indigenous population, government spending on the PBS was much lower for the indigenous population.2,10

The Australian Institute of Health and Welfare report on Indigenous Health Expenditures in 2004-05 revealed that the average income per person for Aboriginal and Torres Strait Islander people was in the lowest 20-30% of all incomes in Australia. The Overcoming Indigenous Disadvantage Report 2007 found that indigenous people are more likely to live in larger households with more dependants and have lower incomes (gross median household income for indigenous adults was $340 per week compared to $618 for non-indigenous adults).11 Low income is a real barrier to buying the large number of scripts often needed by Aboriginal and Torres Strait Islander people with chronic disease.

Indigenous Chronic Disease Package

To assist patients with chronic diseases, the Australian state and territory governments have invested $1.6 billion over four years commencing in July 2009. There is new funding for preventive health, expanding the Aboriginal and Torres Strait Islander health workforce and primary health care.12 Part of the package aims to remove barriers which are reducing access to essential services such as the PBS.

General practices are given incentives to coordinate care for chronic disease. Accredited general practices registered under the scheme enrol and register their Aboriginal and Torres Strait Islander patients who have chronic disease, or risk factors for chronic disease, with Medicare Australia.13 Eligible patients can then give their consent to be registered to receive their medicines at a reduced price.

The assistance scheme commenced on 1 July 2010. Eligible clients’ prescriptions are processed in the usual manner except the prescriptions are endorsed with Close the Gap (CTG) by their doctor. This will enable patients who normally pay the full price of the prescription to pay only the concessional co-payment of $5.60. Patients who normally pay the concessional rate will receive their medicines free of charge. The package will facilitate many more Aboriginal and Torres Strait Islander people having access to PBS medicines, in metropolitan and regional areas across Australia.

It is vital that all prescribing doctors are aware of this initiative so that all their Aboriginal and Torres Strait Islander patients with chronic disease will benefit.

What does this mean for your practice?

Aboriginal and Torres Strait Islander Community Controlled Health Services will have no barriers to identifying eligible patients in their clinic population. In contrast, mainstream general practice may experience problems in identifying eligible Aboriginal and Torres Strait Islander people. General practitioners and practice staff should ask all patients whether they identify as being of Aboriginal and Torres Strait Islander origin by asking the National Standard Identification question ‘Are you of Aboriginal or Torres Strait Islander origin?’.14,15

Once indigenous people are correctly identified and registered with Medicare Australia they are then eligible to access the co-payment assistance. Pharmacists will be reimbursed for the co-payment the patient no longer pays. General practices will be funded through the Practice Incentives Program Indigenous Health Incentive.12

Conclusion

Outcomes in chronic disease will be suboptimal if the patient does not have access to treatment. There are several initiatives which aim to improve the access of Aboriginal and Torres Strait Islander people to PBS medicines. The Indigenous Chronic Disease Package will reduce the cost of prescriptions for patients with chronic disease. This has the potential to help to close the gap in health between Aboriginal and Torres Strait Islander people and other Australians.