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Table 1. PBS statistics by patient category comparing Fixed $ versus Fixed Percentage copayments
ordinary General under
copayment General --
safety net Concessional
-- ordinary Concessional --
free safety net RPBS --
ordinary RPBS --
2016 Copay $c
Government ($millions)e $2,353.81
$0.00 $152.64 $5,103.18
$1,493.18 $266.19 $99.62 $9,468.62
Patient share ($millions) $650.36
$1,623.60 $174.93 $6,043.28
$1,493.18 $319.17 $99.62 $12,757.95
Fixed $ Copayment
Fixed % Copayment
Patient share ($millions) $1,502.08
Difference Fixed % vs
Fixed $ ($millions)
aIncreased 2014--15 PBS scripts by 0.5%
cincreased 2015 Copayments by 3%
destimate of the average under copayment paid by General patients
e Increased 2014--15 PBS $Benefit by 0.5%
b2013-14 undercopayment script numbers increased by 2% source: www.pbs.gov.au/statistics/2013-2014-files/tables-2-2a.pdf
drug if appropriate. Direct price signals
to patients should encourage more
direct cost savings and this could see
more price effective prescribing by
doctors around 25% of savings going to
patients and 75% to government.
The fixed percentage copayment
approach has the added advantage that
copayments don't need to be adjusted
each year as the copayments move
in line with drug prices rather than
inflation. That is, if drug prices go down
then so do patient copayments.
If there are concerns about large
copayments for high cost prescriptions,
then the percentage copayments
could be capped at a maximum dollar
amount for high cost drugs (e.g. $100 for
general and $30 for concessional
patients). Alternatively the copayment
percentages could vary on a sliding
scale similar to pharmacy mark-ups.
This should not have a large impact on
PBS expenditures since less than 10% of
PBS prescriptions are for drugs costing
more than $180.
The SafetyNet process
needs to be revised
The SNTs are based on the dollar
prescription expenditure by a family unit
and the threshold values are adjusted
annually for inflation.
Firstly, it may be better to base the
threshold on the number of prescriptions
a patient takes in a calendar year, rather
than a fixed dollar amount. Ten years
ago, the concessional SNT value was
based on the cost of 52 prescriptions in
a calendar year and this has increased to
60 prescriptions in 2015.
Secondly, more consideration should
be given to the nature of the SNTs, since
they discriminate against singles. That is,
singles must spend the same amount of
money on PBS prescriptions as a family
of five, before they can reach the SNT.
Is there a place for two levels of SNTs:
an individual threshold (30 prescriptions
per year) as well as a family threshold
(60 prescriptions per year)?
In conclusion, there have been major
reforms to the PBS resulting in drug
prices falling, while patient copayments
keep going up. Consequently, a number
of key opinion leaders have expressed
concerns that copayments are getting
too high and they may be adversely
affecting patient access to treatment.
Now seems to be a good is time to take
a close look to see if the application of
copayments and SNTs can be improved
to the benefit of all Australians.
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