Mail order pharmacies haven’t really been a thing in New Zealand. You can find a couple of them on the internet, but they are mainly focused on non-subsidised medicines. Pharmacists I’ve talked to agree that it is part of our health care culture that patients prefer to see pharmacists in person, and most think that it is unlikely that traditional pharmacies are going to face any meaningful competition from mail order pharmacies any time soon.
What’s changed now, though, is that we have a Pharmacy Action Plan, which, amongst other important things, envisages a health system that is “closer to home”. Also, the next Community Pharmacy Services Agreement (CPSA) is currently being negotiated and, as we have been informed at the Guild meeting in Christchurch, some new ideas have been floated by the DHBs that suggest that we may be headed in a direction where the market will become more favourable for mail order pharmacies in New Zealand.
Remote Supply is Prevalent Overseas
In countries where pharmacy is similar or comparable to our system, such as Australia, the UK or the US, mail order is a well established form of obtaining prescription medicines. However, the situation in New Zealand is different due to the country’s small size combined with its isolation from the rest of the world.
Our professional ethics and regulations aren’t overly restrictive, in fact, the Society’s position on this issue is very similar to that of the Australian Pharmacy Board. Remote or indirect supply of medicines is considered suboptimal, because of certain limitations on contact and communication with the patient. Yet, in Australia, online pharmacies are more prevalent and they offer the dispensing and delivery of funded prescription medicines nationwide, whereas in New Zealand dispensing and delivery of prescription medicines is usually limited to non-funded medicines, if offered at all.
The remote supply of medicines is allowed as long as the patient receives the same level of service as compared to direct supply, for example information about the medicine tailored to the circumstances and needs of the particular patient is effectively communicated. In fact, there are many pharmacies that, for many years, have been using depots and other means to send medication to areas that have no access to pharmacies. The difference, however, is that traditionally these remote areas have been serviced exclusively by the closest pharmacy designated for the task, whereas mail order pharmacies can be anywhere in the country and may service any patient regardless of geographical considerations. Clearly, we already have provisions for remote supply that’s been working in certain settings, and could very well work for online pharmacies yet, we haven’t seen many crop up that offer this service for the wider population.
Drivers of Remote Supply Overseas
The most obvious driver of remote supply is demand from patients. It makes sense that the market responds to a particular demand by moving to satisfy it. If patients find it more convenient and desirable to order their medicines without going to the pharmacy in person, then that will be a driver for pharmacies to start offering such a service, unless, of course, there are market regulations in place, such as laws, regulations or professional and ethical obligations against such practices.
In some countries, such as the UK and Australia, demand is the main driver of remote supply. Pharmacies are able to effectively respond to the demand in both of these countries because medicine funding is centralised and pharmacies are allowed to claim for subsidy no matter what part of the country the prescription originated. Consequently, a lot more people are able to fill their prescriptions remotely as they are able to get their medicines at the subsidised price.
Another, not so obvious, nevertheless significant driver of mail order, particularly in the US, is Pharmacy Benefit Managers (PBMs). PBMs are a peculiar creature of the US healthcare system, a kind of middle-person between pharmaceutical companies, insurers, providers and patients. In a nutshell, PBMs administer prescription medicine subsidy schemes and have enormous influence over how subsidy is distributed. PBMs often prefer the use of remote supply, arguably because they often have their own dispensing service for this purpose.
Moreover, there is a thing called mandatory mail order. This means that people with chronic conditions on certain benefit schemes have no choice, but to have their medication sent to them by mail. Their prescription cannot be filled at an ordinary pharmacy and they are not allowed to go and pick up their medicine themselves. Having absorbed the New Zealand health care culture and professional ethics of pharmacy, frankly, the idea of mandatory mail order is disturbing. But I’m not alone with this sentiment. I mean, if somebody doesn’t want to see a pharmacist and finds it more convenient to place an order over the internet, fine, I can relate to that. But it should never be made mandatory as it creates an unreasonable barrier between the pharmacist and the patient. But I digress.
In the US the relatively high prevalence of remote supply is due to the fact that PBMs have a preference for this practice. Pharmacist associations throughout the US have voiced their concerns over this and there certainly seems to be strong arguments going against incentivising, let alone imposing remote supply on patients. I’m not going to go into these arguments, but you can imagine the adherence issues that potentially result in higher hospitalisation rates or other consequential burden on the health care budget, or the increasing medicine waste, and so on.
Enabling Remote Supply
I’ve already touched on the question of funding, arguably, the number one enabler of remote supply in the UK and Australia. In these countries funding is centralised and pharmacies are able to claim subsidy for medicines regardless of where the patient lives or what part of the country the prescription was written. The New Zealand funding structure is different, however. Each pharmacy has an individual contract (the CPSA) with their DHB. This contract specifically prohibits pharmacies from claiming funding for medicines prescribed to patients who reside outside the DHB’s geographical area, or to provide any services to such patients, for that matter. The only exceptions allowed are if there is a prior agreement between the pharmacy and the affected DHBs, or if it’s an isolated occurrence e.g. for a person visiting the area.
This seems to me the main obstacle for an ordinary pharmacy to start a nationwide remote supply service, and I wonder if this is going to change any time soon. What has been proposed, however, during the current CPSA negotiations is somewhat suggestive of a shift towards a more relaxed stance. This is the idea of tiered funding.
Under the current CPSA all pharmacy services and the funding for them are bundled together. The idea of tiered funding is that some pharmacies may opt for a low level service (for example “core services only”), and receive a low level funding in turn. This doesn’t seem like a big deal until you realise that these pharmacies would not be required to provide higher level services, which could result in significant long-term cost savings. However, it would also lead to the erosion of professional standards, which would be in conflict with the spirit of the Pharmacy Action Plan.
Closer to Home
Speaking of the Pharmacy Action Plan, the idea of delivering health care services “closer to home” is a central one in the Plan. In a sense, remote supply achieves just that: medicine delivered to the patient’s home. It does seem an attractive idea, particularly as we have many hard-to-reach areas in the country. Arguably, a remote supply service can be also very useful for people with limited mobility, such as the elderly or those living with disabilities.
However, the key to successful treatment is good communication. Information about the medicine is just as important as the medicine itself. In case of remote supply the pharmacist has to make sure that, despite the lack of personal contact, there is some alternative method of communication, which is equally effective to convey the information necessary for the patient to ensure safe and effective use of the medicine.
Providing information sheets, leaflets, brochures may be a good starting point, but the pharmacist’s role is to engage in a two-way communication with the patient, to provide individualised advice in order to optimise treatment outcomes. The PSNZ’s position is that the patient is entitled to the same high quality care from the pharmacist, regardless of the mode of delivery.
A More Favourable Market?
Without a doubt, the health system is ever changing and developing. Innovation in science and technology keeps pushing the limits and we must face it, remote supply is not going away. Sooner or later, innovation in this area will produce a solution for remote supply that meets the required standards.
As pharmacy regulations change, for example, around licensing requirements, or the CPSA gets restructured with more enabling clauses, the market starts to become more favourable for unconventional practices. This is a time when traditional pharmacies can expect competition from new players who are able to take advantage of the new situation. While traditional pharmacies can leverage on their good will and their established resources, new entrants have the advantage of being able to align their business model with the new rules from the get-go. Meanwhile, we have to make sure that our high professional standards do not fall victim of the strong competition.
For now, the only thing we can say with certainty is that these are exciting if somewhat stressful times to be pharmacists.
