Annual Review 1995 (text extract)

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PHARMAC III

Pharmaceutical Management Agency Ltd

for the year ended 30 June

Treating more patients. Slowing budget growth.

PHARMAC (Pharmaceutical Management

Agency Limited) was established in mid-1993 to manage the national Pharmaceutical Schedule on behalf of the four RHAs (Regional HealthAuthorities).lt is a not-for-profit Crown agency owned equally by theRHAs. The Schedule is a list, updated monthly and reprinted three times a year, of more than 2,500 subsidised prescription medicines and related products available in New Zealand. The Schedule also records the price of each pharmaceutical, the subsidy it receives from public funds, and the guidelines or conditions under which the pharmaceutical may be prescribed. Decisions on subsidy levels, and prescribing guidelines and conditions, are taken by the PHARMAC Board with input from independent, medical experts on the Pharmacology and Therapeutics Advisory Committee (PTAC), and PHARMAC's managers and analysts. In taking its decisions, PHARMAC seeks to balance the needs of patients for equitable access to health care with the needs of tax payers for responsible management of the costs they ultimately bear.

Inside

Two views on PHARMAC's goal of more cost-effective drug use

• PHARMAC's chairman says New Zea landers are we ll served by a system that gives more peopl e access to the drugs they need - whil e slow ing down th e escal ating cost. • The chairman of the Pharmacol ogy and Therapeutics Advisory Committee (PTAC) says doctors have a vital ro le to play in decisions about resource allocati on.

A global issue - meeting patients' needs on tighter budgets

The implications of the world-wide trend for drug costs to esca late are di scussed by PHARM AC 's general manager. He looks at the reasons, the signs on the horizon that promi se cost reducti ons, and anomalies in prescri bing behaviour.

~ . ~On

Better access - better targeting

The issues are rev iewed by therapeuti c group . The result is bette r treatment fo r more pati ents, better targeting of drugs, and annual cost sav ings of $25 million.

Strategies for balancing need and cost

PH ARM AC's three strategies fo r balancing patient needs and costs.

The operations of PHARMAC

How PHARMAC is stri ving fo r greater effic iency and quality.

The numbers

Data on drug groups by subsidy cost, and the top 30 by increase in subsidy cost.

Who's who in PHARMAC and PTAC

Two views on P-_ goal of more OS-

Information is a key to more rational prescribing.

PHARMACEUTICA L MANAGEMENT AGENCY LTD

AC's

Denis Tait, PHARMAC's chairman, says that although the rate of increase in the number of scripts is sLowing, more peopLe are getting access to the drugs they need.

n the yea r ended 30 June 1995, some 22 million prescriptions were writte n in New Zea land fo r pati ents requiring medi cines and special foo ds. That is an average of abo ut six scripts for every wo man, man and child . The subsidy cost ranges fro m $22 a year, for the antihypertensive bendroftuazide, up to $87 ,000 a yea r, for octreotide (Sandostatin) for the treatment of acromega ly. The total cost in the year was $674 milli on, including GST, or about $3 0 per prescription. One view of thi s information is that it depicts a nation of pill -poppers. A more measured view is that it depi cts a normal, western nati on taking full adva ntage of the imp ress ive array of benefic ial treatments that inte rnational medica l technology offers. The gross da ta is not, however, as instructi ve as what li es behind it:

• A major new area of ex penditure growth is in se lective serotonin re-uptake inhibitor (SS RJ ) antidepressants, whi ch are probably being consumed by 1.5 per cent of the population. Other new areas of rising expenditu re are in treatments for other di sorders of the central nervous system and osteoporos is. • There are areas, such as epilepsy, herpes, and asthma where many more people are being treated as a res ult of more liberal access to some drugs . • Pri or to PHARMAC's establi shment, the cost to the tax payer of pharmaceuticals was risi ng by up to 10 per cent a year. 11 is now rising by about five per cent, or about $30 milli on a yea r. In short, more peopl e received more medicine in the year ended 30 June 1995 than in the yea r before. In an enviro nment of capped hea lth care budge ts, PHARMAC has done we ll for the hea lth care of New Zea landers. It is an ac hi evement that many countri es with health care systems partly- or wholly- funded fro m the publi c purse would like to emulate.

• The number of subsidi sed prescrip tions increased last yea r by seven per cent. • A significant proporti on of the growth is in the management of cardiovascul ar illness, including such trea tments as angiotensin converting enzyme (ACE) inhibitors, calcium channel bl ockers (CCBs) and, increasingly, lipid modify ing drugs .

Denis Tait

Chairman

30 October 1995

John Hedley, Chairman of the Pharmacology and Therapeutics Advisory Committee (PTAC), says the ethical dilemma is between the needs of individual patients and duty to society.

Participation in PTAC or one of its sub-committees is often a salutary experience. At the very least it is instructive. A doctor, whether in specialist or general practice, soon finds that there is a world of difference between: • making judgements based on years of practice (or bias) to write a script for a patient in need, and • critically appraising a ten centimetre high stack of literature representing the sum of scientific knowledge about a particular drug. Despite the imperfections of muc h of the data, and the divergence of opinions, we usually manage to reach a consensus view about the value of a drug for particular groups of patients. Occasionally, a PTAC member has a dissenting view and this is recorded in the minutes. The forthcoming year will bring its own challenges. We don 't want New Zealanders to regard pharmaceuticals as a lolly scramble. Clear heads are required in making resource allocation decisions of this complexity and substance. It is imperative that practising med ical practitioners are involved in this. The ethical dimension needs to be exp lained and conflicts of interest uncovered. I feel medical professionals tend to weight heavily the ethical responsibility they have to the individual patient, but of equal importance is the competing duty of care to society and the tax payer. To some extent responsibility is abandoned when resource allocation is left to non medical persons. It's not good enough to vacate the difficult debate and complain after the event.

SIX TYPES OF LISTING

To improve targeting

he work programme for PTAC over the last yea r has been greater than ever before. The pressures on members have increased in part because of the number of therapeutic group reviews and the conduct of work in a more open environment with a more informed public.

The Pharmaceutical Schedule provides for six categories of listing:

Listed

Most drugs are in this basic category.They may be prescribed by any qualified medical practitioner. and in some cases by dentists and midwives.

Retail pharmacy-specialist prescription

Prescriptions may be written only by a medical practitioner in the specialist category defined in the Schedule. Any retail pharmacy may dispense.

Retail pharmacy-specialist

Prescriptions may be written by a general practitioner on the recommendation of a specialist.Any retail pharmacy may dispense.

Hospital pharmacy-specialist prescription

Prescriptions may be written only by a medical practitioner in the specialist category defined in the Schedule. Only hospital pharmacies may dispense.

Hospital pharmacy-specialist

Prescriptions may be written by a general practitioner on the recommendation of a specialist.Any hospital pharmacy may dispense.

Special Authority

A prescription may be subsidised only after approval is obtained from Health Benefits Limited (HBL).This is granted. on the application of a practitioner (usually a specialist). to patients who meet the criteria defined in the Pharmaceutical Schedule. More than 90 per cent of applications are approved within a few days; and HBL is working on further improvements to its processes.

PHA RM ACEUTI CA L MANAGEMENT AGENCY LTD

Far better to analyse the ethical dilemma, ensuring al l perverse incentives and conflicts of interest are apparent, and to make a recommendation on interim resource allocation in the best interests of all patients. Until we reac h that point, our decisions wi ll lack the rob ust character necessary to argue for increases in resources . I take this opportunity to thank all the members of PTAC and its sub-committees for their considerable contributions during the year. I also thank Gavin Kellaway for his contribution over many yea rs.

PHARMAC's DECISION CRITERIA

Seeking best health value for the pharmaceutical dollar

PHARMAC seeks to operate in an open, transparent and accountable way. Its reviews and changes to the Pharmaceutical Schedule are governed by its Operating Policies and Procedures - a public document developed in consultation with the pharmaceutical industry.The document emphasises the importance of basing decisions on the latest research-based clinical information, and it sets out criteria to be taken into account in decisions about the Schedule.These criteria are: • the health needs of all New Zealanders, • the availability and sUitability of existing medicines, therapeutic medical devices or related products to meet health needs, • the clinical benefits, risks and costs of new medicines, therapeutic devices or related products, • the cost-effectiveness of meeting health needs by purchasing pharmaceutical services rather than by purchasing other health care and disability services, • the overall budgetary impact of any changes to the Pharmaceutical Schedule, • the direct cost of pharmaceuticals to users, • any recommendations on core health and disability services made by the National Advisory Committee on Core Health and Disability Support Services (Core Services Committee), and any other matters that PHARMAC sees fit.

John Hedley Chairman Pharmacology and Therapeutics Advisory Committee

PTAC's PURPOSE AND STRUCTURE

Independent, expert evaluation and advice

The primary purpose of the Pharmacology and Therapeutics Advisory Committee (PTAC) is to provide PHARMAC with independent advice on the pharmacological and therapeutic consequences of proposed amendments to the Pharmaceutical Schedule. PTAC is a committee of medical specialists and general practitioners nominated by such professional bodies as the New Zealand Medical Association, the Royal New Zealand College of General Practitioners, the Royal Australasian College of Physicians, and the Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists. PTAC's work includes considering and making recommendations on the medical implications of: • All significant applications by drug companies for inclusion on the Schedule, or amendment to it;

• Requests by PHARMAC for de-listing; • The management of the Schedule; and • The need for reviews of specific drugs, or groups of drugs. PTAC's focus is on general medicine, but increasingly it seeks advice from known specialists or experts. It also consults with the Core Services Committee, sets up sub-committees for specific tasks, and sometimes undertakes its own literature searches. PTAC members and those co-opted to sub-committees are paid an hourly rate plus expenses for attendance at meetings and time spent preparing for meetings. Full meetings of PTAC are usually held in Wellington at least four times a year.

global issue -meeting

a ien s'nee s

•

Balancing care and cost.

PII ARVl AC I:-.l;TI CAL M ANAG I·. M ENT AG ENC Y ITn

ets

t is ironi c that, at a time when medi ca l sc ience is abl e to tackl e human disease more effectively than ever before, hea lth care has become one of the dominant topics on the politi ca l and media age nda of ma ny western nations. We ta ke comfort from growing life ex pectancy and growing certai nty that di sease can be treated; but we worry about equ ity ("is el'elJbod), gelling/air and reasonable access "), morality, and ethics ("who decides Ihe patient priorities on access to scarce resources? ") Underlying the debate is concern abo ut cost ( "can we meet the escalating bills"). The fo ll owing snippets, from internatio nal medica l medi a, are illustrati ve :

• In Australia, cost benefit guidelines and generic substitution have been introduced to control expenditure growth .

Multiple reasons for rising costs

The inexorable rise in the cost of pharmace uticals is probably due to a combination of the foll owing:

The "free good" phenomenon

A well -demonstrated economic phenomenon is that there is in fi nite consumer demand fo r a "free good." For severa l yea rs, most prescriptions in New Zea land cost the patient nothing. There is anecdotal evidence that during these yea rs (and subsequently, but probably to a lesser extent) doctors over-prescribed and prescribed more expensive medicines rather than lowercost alternatives (a lthough usually in those days they we re not awa re of the pri ce).

• In the UK, a health committee of the House of Commons says that, although not a major cause fo r alarm, continuing esca lation of costs in rea l tenl1S will inev itably put mo unting pressure on overall resources, and that there is scope fo r signi fica nt savings in drug expenditure. • III Callada, a review Board conducts price reviews on patented medicines, recommends pri ce guidelines and seeks vo luntary compliance by drug companies. • In Germall.\', legislation has been introduced on reference pri ci ng; and budget reducti ons have been imposed on doctors. • In the Netherlands , the pharmace utica l industry has sought to fo restall legislative ac ti on by pro pos ing price cuts to new refere nce price leve ls. • in Denmark, a new governm ent proposes to reduce pharmace utica l costs by obligatory generic substituti on, and therapeutic substi tuti on by pharmac ists. • III Italy, the drug budget is capped and a price-freeze imposed on non-reimbursed drugs pending di scussions between the pharmaceutical industry and the government on a "correct policy fo r drugs and their prices." • In Frallce, the national hea lth in surance agency, concerned at what it believes to be high prescribing leve ls and at a trend for French doctors to prescribe the more expensive drugs, initi ates talk s with doctors to see what arrangements can be made to encourage more cost-e ffective prescribing.

Users want the best

Give n a choice, espec ially when there is little di ffere nce in the price the end-use r pays, prescribers and use rs will , understandably, opt for "the best." One mani festa ti on of this is in the side-effect profi le of a drug. A new drug that is known to have fewe r sideeffects in some patients, is often perceived to have fewer side effects in all or most patients. The result is ri sing demand fo r the new "clean" and "best" drug, even though the lower-priced drug used fo rmerly may be adequate for many patients. An example is the use of SS Rl s versus the older tricyc lic antidepressants that have served us we ll fo r years. The international drug companies play to this phenomenon by heavily pro moting "new" products, sometimes directly to the consumer. Recentl y, fo r example, a treatment for prostate condi tions in men was adverti sed on television and in the press. There is also a continuous stream of experts , usually fro m overseas, who market their sponsor's wa res to user groups and the medical media.

Greater use by aging populations

We know that medical care costs rise significantly among people aged 60 and over and we know that the mean age of the popul ation in most western coun tri es is rising. We might surmi se therefore that aging populations are a reason for rising drug costs. Unfortunately, we do not have suffic ient reliabl e data to enable us to quanti fy the impact of age on the cost spiral compared with the impact of other cost pressures.

The balance of market power

The international drug companies are large, sophisticated in their marketing, occupy a powerful position in research, and are protected by patent laws and regulatory barriers to free trade. The combination of these strengths means that the balance of market power between vendor and purchaser tends to be tilted in the vendor's favour. It means that purchasing agencies such as PHARMAC are often price takers. Although some competition occurs from me-too drugs, significant price competition does not occur until the patent expires. The drug companies say they need high profit margins on patented med icines to recoup their substantial investment in research and development. However, the position may not always be as the companies say it is. There is no doubt that they seek to recover R&D costs through the price of each new drug, and their success in this is evident in the leading position many of them occupy on the performance tables of the world 's share markets. Drug companies are under pressure to maintain that performance and one consequence of this is industry rationalisation. Merger or takeover examples inc lude: Glaxo and Wellcome, Hoechst, Ro usse l, and Marion Merrell Dow, Pharmacia and Upjohn , and Roche and Syntex. Where the rationalisation has market dominance as its goal, the outcome is likely to be improved profits for the merger partners, rather than lower prices for pharmaceutical users.

New and changing diseases and therapies

The outstanding examp le of a new disease that has major implications for health costs is AIDS ; but cost pressures are also coming from less visible sources. There is now, for example, greater recognition of mental hea lth issues, and in particular depression. There is a growing dynamic between awareness of certain conditions, for example mental illness, the avai labi lity of new and helpful drugs and the use of more expensive and more aggressive therapies by prescribers. There are also new treatments emerging for degenerative diseases, such as Alzheimer 's and motor neurone disease. The combination of these new, and costly, drugs and an aging population have the potential to cause major cost blow-outs.

Responses to rising costs

The outlook on rising costs is not, however, entirely gloomy. A number of trends seem to be emerging that hold promise for holding back the cost esca lation, if not achieving real reductions. They include:

Government and health insurer pressures on price

Governments, government agencies suc h as PHARMAC, and health insurers are having varying degrees of success in their efforts to restrain the growth in pharmace utical and health care costs. As these efforts increase, it is likely that new and innovative too ls wi ll be developed that improve the delicate balance between health needs and cost. A priority in most of these efforts is better targeting for a better fit between need, outcome and cost. Information technologies will play a growing role in targeti ng because they improve our ability to acquire, access, analyse and disseminate data.

THE CONTENTIOUS BATTLEGROUND

"The seemingly unending road to reform arises from the essential complexity of pharmaceuticals as an object of reform.The entire spectrum of social behaviour, in both its desirable and undesirable manifestations, is apparent in and through the domain of drugs; the acquisitiveness yet entrepreneurship of drug firms; the professional arrogance yet altruism of physicians; the self-righteousness yet selflessness of advocacy groups; the isolation yet intellectual integrity of academics; the confusion yet compassion of governments.All these tendencies, because of their inherent contradictions, operate, interact, and ultimately collide in the contentious battleground that is pharmaceuticals."

- From keynote address to a World Health Organisation (WHO) con(erence in Sydney, Odober 1995, by AI(redo RA Bengzon, MD, MBA.

Growth in availability of me-too or generiC drugs

The growing avai lab ility of generics and me-too drugs is introducing new competitive pressure on price; but for the reasons outlined above, some of the costreduction potential is being lost in perceptions that such drugs are not always "the best."

PHARM ACEUTICAL M ANAGEM ENT AGENC Y LTD

A trend to cures instead of pills

Chronic disease is a fertile market for the pharmaceutical industry and a major segment of most countries ' drug expenditure. At PHARMAC, and in other countries, we are therefore putting more emphasis on disease management and cure; on how best to achieve a given patient outcome, rather than amelioration of the condition. For example, because we know that the bacteria H. pylori is closely linked to stomach ulcers, an appropriate long-tem1 strategy for reducing drug costs must be to treat the source rather than the symptoms.

I also emphasise that I believe New Zealand doctors are now very much more aware of the need to carefully weigh patient needs with costs when prescribing. To this extent, Professor Garratini 's view is less relevant to New Zealand than to Europe.

PHARMAC's position

From the outset, PHARMAC's preferred approach has been to work in partnership with medical practitioners, pharmacists and the pharmaceutical industry. However, there are times when tough decisions have to be made, for examp le to decline subsidy to a new drug. Typically, this occurs when there is no evidence of improved efficacy over ex isting, lower-cost alternatives. On the other hand, if there is evidence of improved efficacy for some patients under particular circumstances, then we will make a subsidy avai lable but only with criteria that ensure that the drug is used only by those to whom it wi ll de liver maximum benefit. PHARMAC does not lack compassion. It has a job to do and that job is described, formally, in PHARMAC's statement of medium- and long-term goals: "To optimise pharmaceuticals' contribution to health status relative to other therapies."

Variations in prescribing behaviour

An issue that casts more gloom than light on any endeavour to balance health needs with cost is the wide variation in the way drugs are prescribed. A recent study by Professor Silvio Garattini of Italy 's Mario Negri Pharmacological Research Institute, reported in the international pharmacological newsletter Scrip, identified striking anomalies in drug prescribing patterns between the UK, Germany, France and Italy. It found, for example, that only seven drugs appear in the top 50 by value in all four markets. They are acyc lovir, captopril , enalapril , nifedipine, ranitidine, omeprazole and simvastatin. Professor Garattini concluded that this was probably due to "fads, cultural differences, and industry pressure" rather than any significant variation in disease patterns. "Despite all the complaints about excessive expenditure on health , at least 20 per cent of the sales of the top 50 drugs in Italy and France, and 12 per cent in Germany, are a waste of money. These three countries would do well to look at the reasons for this to see how they could spend their resources more wisely," he is reported to have said. Professor Garratini 's opinion highlights one of the key issues for the health sector: "How to use pharmaceuticals more effectively, efficiently, and equitably, for the benefit of more people." We are confident, at PHARMAC, that we have started to achieve precisely that. As we acquire more and better data, develop better tools, and build the confidence of the medical profession and the drug industry that we share a common purpose, the gains should grow.

David Moore General Manager

Better access-

A review of the steps PHARMAC is taking to improve access to drugs, and encourage more effective use.

PII ARMACI. UTI('A I M Ai\A(i EMI. Nl AG I'NC Y LID

•

he core activity of PHARMAC is review and publi cation of regular Updates of the Pharmaceutical Schedule. Th is involves contlllUal assessment of drug performance and cost, usually by reviewing trends with in defined gro ups of drugs (therape uti c group reviews), and by process ing appli cations from drug companies for li sting of their products on the Schedu le. Considerable emphasis is put on consultation, and the need for innovative so luti ons that either reduce the cost or the rate of growth in cost. PHARMAC sets its review priorities by taking into account the reports of the Core Serv ices Committee, known patient needs, the size of the therapeuti c group relative to total drug usage, and cost trends within that therapeutic group. The bill for subsidised pharmaceuticals has been growing by up to 10 per cent a yea r, but as a result of PHARMAC's efforts, thi s rate has slowed to about fi ve per cent a yea r. (See graph one). The total drug bill is dominated by cost in four maj or therapeutic groups. (See graph MO).

Issues

In the 1970s and 1980s, a major investment was made in treating large numbers of patients with expensive antihypertensives . With the benefit of hindsight, much of thi s investment may have been wasted, because considerable opinion now suggests that many cou ld have been successfu lly treated with less costly drugs. With the advent of new therapies, for example statins, and in particular simvastatin, PHARMAC is concerned to avoid a repeat of the mi stake by ensuring that the new therapies are received only by those patients who will derive significant benefit from them.

Graph o nc

SUBSIDISED DRUG I NVESTMENT Yea rs elided 30 )ulle $ milliolls

641

674

Actions

Review ofACE inhibilors. A decision will be made in early 1996 on therapeutic sub-groups. Subsequent reference pricing should result in substantial cost savings. Review o(CCBs. A proposed therape utic sub-grouping of CC Ss has been sent to suppli ers for comment prior to PHARMAC establi shing reference pricing for these therapi es. The committee stud ying CCS use is concerned that although CC Ss are second or third line treatment age nts in most situations, expenditure fi gures indicate that they are often being inappropriately prescribed as first-l ine treatment. Lisling of dillia::em. Savings of S575,000 a year resulted from negotiations with new suppliers and the appl ication ofreference pricing. Dipyridamole. A review found that a combination of dipyridamole and aspirin is no more effecti ve than aspirin alone, and resulted in savings of $3.0 milli on a year. Spec ial criteri a for subsidy were established and will be reviewed in the yea r ahead. Lipid modifying agents. Thi s priority revi ew was initi ated because of: ri sing costs; a shift in medica l opinion about the management of dysl ipidaemia; and some evidence that the agents are not being targeted to those peop le most at risk. Most of the recent growth is in the prescribing of statins, in particular simvastatin. A sub-committee of PTAC has reviewed the cli nical literature and PHARMAC is modelling the economi c impact of proposed new guide lines.

600 ~ 556 ~ 582 500 -; 400

--j

300 -200 -100 -

I-92 93

I--

I-94

.95

eST

Estimated distri/mting margins alld dispensing./ee,\·. COSI. lI el o/"c"mges alld /(IX.

Cardiovascular and blood

Gr a ph t wo

Cost trends (See graph three)

More than a quarter of the total annual subsidy cost of $16 1 million in cardiovascular drugs is in angiotensin converting enzyme (ACE) inhibitors. About a fifth is in ca lcium channel blockers (CC Ss). The subsidy cost of both rose by more than 10 per cent over the year. The estimated subs idy cost in the yea r ahead of lipid modifyi ng agents is $15 milli on, following a yea r of 26 per cent growth. If access is widened, an extra $30 million investment may be needed.

INV ESTMENT BY THERAPEUTIC GROUP Y elided 30)ulle 1995 ear

Cardiovascular alld blood

(27%)

RespirarOl:v tra ct and al/elgies

(18%)

•

Alimell/(ll"l' lracl alld lIle/(lholis;1I (1 4%) Nervous 51'SIem (12%) All ol"er (29%)

•

Respiratory tract and allergies

Cost trends (See graph foUl)

New Zealand's high prevalence and high severity levels of asthma are reflected in the annual cost of respiratory tract and allergy drugs relative to other developed countries. These account for $111 million, or about 18 per cent of the total annual subsidy bill. The two largest areas of cost are in inhaled corticosteroids and bronchodilators.

Nervous system

Cost trends (See graph five)

Total expenditure was $72 million, up 16 per cent on the previous year. The largest component of this growth was in the use of the new selective serotonin re-uptake inhibitors (SSRIs), where the current growth rate is about 30 per cent. PHARMAC agreed to meet the rising demand, and by year end, additional expenditure was nearly $5 million.

Graph thr ee

~-----~---

CARDIOVASCULAR AND BLOOD INVESTMENT

Years ended 30 June $ millions before eST

161

I 50 ~~---,--~~=o-----l 1 49

Issues

Past investment in inhaled corticosteroids has delivered lower mortality rates and improved health to asthma sufferers. PHARMAC's view is that new drugs and therapies should be targeted to those patients with the most severe conditions; and that savings should be sought by encouraging more generics into the inhaled corticosteroid and bronchodilator markets, and through more cost-effective prescribing.

Issues

Significant trends include: the availability of new drugs for the treatment of depression, epilepsy, schizophrenia, and degenerative diseases; growing public awareness of depression ; the adoption by some doctors of more aggressive therapies for the treatment of depression ; a commitment by government to give a priority to expenditure on mental health services.

100

o ---'________

92 93

L-.J____

Actions

Antidepressants. Review of antidepressant drugs and the management of mental illness is now in its third year. PHARMAC is looking at prescribing patterns for SSRls, taking into account evidence that there is some inappropriate prescribing for mild depression and other indications. PHARMAC is also working closely with psychiatrists and GPs in the preparation of prescribing guidelines to increase access. Clozapine and risperidone. PHARMAC recommended that c1ozapine, a new drug for use in treatment-resistant schizophrenia, be subsidised through drug-inclusive contracts with providers of mental health services. Under consideration is a subsidy for risperidone, another new treatment for schizophrenia. Antipsychotics. Patient premiums were removed on some antipsychotics as a result of PHARMAC increasing the subsidy for some drugs in this group and the pharmaceutical supplier reducing the price to match the current subsidy. New listings. Two new drugs were listed for the treatment of epilepsy - lamotri gine (Lamictal), and vigabatrin (Sabril). The budget for the two has an annual cap and is controlled by prescribers . This is the first use of a novel system aimed at balancing patient needs and restraining cost.

Actions

Asthma review. A review of asthma medications was started in June 1994 and completed in August 1995. This resulted in the establishment of new therapeutic groups based on clinical effects and a new reference pricing structure. In the five cases where product prices were not lowered to the new subsidy levels, fully subsidised alternatives are available. The estimated saving is $2.9 million a year, without compromising patient health . Asthma spacers. A decision was taken, in advance of completion of the review, to subsidise a spacer device for children under six because there was strong evidence of the effectiveness of such devices in improving child asthma. This decision was widely publicised with the full support of the Asthma Foundation. New listing. A contract for a new prophylactic, nedocromil (Tilade) was agreed for implementation from August 1995. Pulmozyme. A decision was taken not to list this drug after PTAC advised that there was little evidence that it offers significant benefit to the cystic fibrosis population as a whole. New generics were listed in the inhaled corticosteroid and bronchodilator markets with resultant savings of $4.9 million in a full year. Peakjiow meters. Quality standards are now defined and reference pricing introduced.

ACE inhibitors and CCBs are contributing significantly to recent growth.

Graph f o ur

RESPIRATORY TRACT AND ALLERGIES INVESTMENT

Years ended 30 Jun e $ millions before eST

107 102 100 103

I1 1

o L

Improved targeting of lIew therapies should help hold costs.

PIIARMACEUT1("AL MANAGEMENT AGENC Y LrD

Morphine liquid. Because of the potentia l for improving quality, it was decided that commercially-prepared morphine liquid should be subsidised by RHAs. The health benefits (stability and quality) should outweigh the increased cost to RHAs.

Special foods. Another annual review was initiated by an advisory committee. This included consultation with paediatricians, dietitians, gastro-enterologists, and other specialists. The committee is considering: new Special Authority criteria to improve targeting, taking greater account of user needs and access; improved distribution ; and review of recent applications for subsidy. Diabetes test strips. A quality review has been commissioned to ensure that only reliable products are subsidised. Diabetes review. The issues relating to the management of diabetes are being considered and a review is likely to start in the 1995-96 year.

Graph five

NERVOUS SYSTEM INVESTMENT

Years ended 30 June S millions before CST

62 55 50 50

Alimentary tract and metabolism

Cost trends (See graph six)

Total expenditure was $84 million, up two per cent on the previous year. The largest areas of cost are H2 antagonists which last yea r cost about $26 million in subsidies and had volume growth of 14 per cent, drugs for the management of diabetes, and proton pump inhibitors (about $8 million, with 53 per cent growth).

25 -

92 93 94 95

IncreasedJilllding is heing provided for mellfol health thempies.

Infections

Cost trends (See graph seven)

Total expenditure was $47 million, although growth slowed to 10 per cent in the yea r - from 20 per cent the previous yea r. Most of the growth appears to be related to an increase in the use of antibiotics.

Graph six

Issues

A marked shift appears to be taking place in prescribing patterns, particularly in the use of proton pump inhibitors and H2 antagonists, for the treatment of gastro-oesophageal reflux disease (GORD). Currently, the guidelines for proton pump inhibitors include inappropri ate criteria for access by income. PHARMAC is considering new Special Authority criteria that give access to patients most likely to benefit. Because the role of H. pylori in stomach ulcers is now well understood, a key strategy of PHARMAC is to provide access to treatment to eradicate or reduce the incidence of thi s bacteria.

ALIMENTARY TRACT AND METABOLISM INVESTMENT

Y ears ended 30 June

$ millions before CST

75 - - 72 64

50 ttf-

Issues

PHARMAC is concerned that the volume of antibacterials prescribed continues to rise when there is no evidence of a change in the prevalence of bacterial infection. A slow-down in growth appears to be due to: a maturing, and therefore more competitive, market for several broad spectrum antibiotics, particularly roxithromycin and ciprofloxacin; no new antibiotics being li sted (applications for new cephalosporins and a macrolide were declined because they offered little health gain for significantly increased costs); and the possible impact of prescriber budget holding. The latter appears to be bringing a more critical approach to prescribing. Evidence of this is in the recent increase in the use of phenoxymethylpenicillin and erythromycin.

25 -

I-

Actions

Proton pump inhibitors. Lan soprazo le (Zoton) was listed from October 1995 under improved access criteria that do not have income barri ers.

H. pylori. PHARMAC called for expressions of interest

Potential exists for savings fi"O/n neH' therapies,

Graph seven

from suppliers of eradication packs. A sub-committee is considering who should be treated and with what combination of drugs .

Vitamin D derivatives. PTAC is reviewing the efficacy of vitamin D derivatives. Guidelines for the treatment of osteoporosis are being considered. Vitamin D and E liquids. Access to these preparations was extended to infants and children with liver disease and short gut syndrome.

INFECTIONS INVESTMENT

Years ended 30 June 5 millions before CST

43 40 31 30 ----f"'"r---'

Actions

Antibiotics review. A series of reviews aims to maintain access to newer antibiotics while ensuring that older, cheaper alternatives are used where these will provide a successful cure. A proposed review of the macrolide group of antibiotics is scheduled for completion in December 1995 .

! -

20 -

r-~

10 -

93 94

SOllle evidence of cost slow-doll'lI.

Graph eigh t

Antivirals. Following a constructive negotiation with Glaxo-Well come, an arrangement was put in place to provide greatly increased access to acyclovir (Zovirax) tablets for the treatment of herpes in exchange for price reductions and a risk-sharing agreement. The result is increased patient access to treatment (40 per cent more volume in the year) without equivalent expenditure growth. Development oJ prescribing guidelines. A forum comprising medical specialists, microbiologists, pharmacologists, general practitioners, and PreM eC is considering guidelines for prescribing antibiotics. Lowered subsidies. Lowering of the subsidy on cefaclor (Ceclor) suspension resulted in potential savings of $550,000 a year; and on minocycline (Minomycin) tablets and capsules, potential savings of $200,000 a year.

Hormone preparations

Cost trends (See graph nine)

Total expenditure on drugs in this area in the year was $21 million . The trend is for an annual increase of about $2 million.

MUSCULO-SKELETAL INVESTMENT

Years elided 30 JUll e $ lIIilliolls before GST

27 26

25 25

Actions

Hormone replacement therapy (HRT) review. This priority review of hormones for the reduction of cardiovascular risk and osteoporosis in post-menopausal women started after the end of the year in response to a Core Services Committee report. A sub-committee of PTAC, comprising spec iali st clinicians, is evaluating all evidence and submissions in conjunction with the Core Services Committee 's findings. An area of special attention is the use of transdermal treatments. The Core Services Committee said this was an expensive form of treatment at more than double the cost of oral oestrogen with no known advantage over oral oestrogen except for women with specific medical conditions such as significant liver di sease. New listing. A new listing was approved from July 1995 for leuprorelin (Lucrin) for the treatment of prostate cancer under Special Authority.

'-----

Musculo-skeletal

Cost trends (See graph eight)

In contrast to most drug groups, current subsidy costs on drugs in thi s area - mainly nonsteroidal antiinftammatories (NSAIDs) - are declining mainly due to competition from generics.

Generic cOlllpelilioll has lowered cosls.

Issues

Graph nine

There is growing medical concern about the safety and inappropriate use ofNSAlDs.

Other

Dermatologicals. Daivonex cream was listed at a price that enables the premium to be removed, thus easing access for psoriasis patients. Oncology agents and immunosuppressall!s. Restrictions on interferon were amended to improve targeting. Genito urinary. Price negotiations with suppliers led to savings of several hundred thousand dollars in subsidy costs. A priority for 1995-96 is to review the premiums on ora l contraceptives.

HORMONE PREPARATIONS INVESTMENT

Years ended 30 JUlle $ lI1illiOIlS before GST

Actions

NSA ID review. PHARMAC is seeking to establish new therapeutic sub-groups for reference pricing. The review is helped by a sub-committee comprising a sports medicine specialist, rheumatologist, a GP and other specialists. A recommendation on reference pricing is expected to go the board by early 1996. The subcommittee will then develop guidelines for the most appropriate use of NSAIDs to minimise medical risks. Rheumatoid arthritis. PHARMAC is considering an application for the use of cyclosporin.

18 16

19 -

t--

15 -

t--

10 -

I-

t--

L---

'------

L---

'------

Costs continue to rise.

PHARM ACEUTI CAL MANAGEME:-JT AGENCY LTD

THREE STRATEGIES FOR BALANCING HEALTH NEED AND COST

PHARMAC employs three strategies to balance patient needs and costs.

and the newsletters of the supplier company and the Foundation. With lamotrigine (Sabril) and vigabatrin (Lam ictal), new anti-epileptic drugs, patients get access but the financial risk is managed through a capped budget and clear guidelines. For patients who do not show benefit, the therapy is discontinued.

Price competition

Price competition is achieved mainly through reference pricing. This involves classifying pharmaceuticals into therapeutic groups and further into subgroups.A therapeutic group is a set of pharmaceuticals used to treat the same or similar conditions.A sub-group is a set of pharmaceuticals that produce the same or similar therapeutic effect in treating the same or similar conditions. For example, ulcer healing agents form a therapeutic group, while H2 antagonists form a sub-group.This sub-group comprises cimetidine, ranitidine, famotidine and nizatidine. The subsidy for each is equivalent to the price of the least expensive brand of H2 antagonist available. Reference pricing is highly effective and is one of PHARMAC's most powerful tools. It reduces market segmentation based on brand marketing, which previously allowed suppliers to establish markets that were free from price competition.

Risk sharing

• Price/volume contracts between PHARMAC and the supplier recognise

that rising volume invariably results in lower marginal costs for the supplier.Typically, the contract will be at a fixed (or diminishing) price for a fixed (or increasing volume). Many generics are in this category.

• Average daily dose contracts shift the risk of increasing dosages of a drug

to the supplier.An example of such a contract was with paroxetine hydrochloride (Aropax).A contract was negotiated with the supplier that tied the subsidy at an average daily cost that, in this instance, also corresponded to an agreed average daily dose of 20mg.The supplier gave a rebate when the average daily dose was exceeded.

• Capped maximum annual contracts. Under these contracts, PHARMAC

Improved targeting

Some pharmaceuticals are more expensive than alternative treatments. Often they are slightly more effective than alternative treatments for many patients, perhaps because of better side effect profiles. Sometimes, they are much more effective for some patients than alternative treatments, for example the new anti-epileptic drugs. One approach to such drugs is to develop, and widely disseminate, prescribing guidelines. These guidelines are drawn in cooperation with the relevant medical specialists and their professional colleges, and user groups. With acyclovir, for example, the Herpes Foundation was consulted, and the final guidelines were published in the Pharmaceutical Schedule,

pays a maximum annual fee for patient and prescriber access to a drug regardless of the volume prescribed or the number of patients requiring treatment. It provides a good balance between incentives for doctors who want to prescribe the best drug for their patients, and suppliers who want to market enough volume to reach the maximum annual fee at a given price, but no more.An example is acyclovir (Zovirax), where subsidy expenditure is fixed for five years at a fixed growth rate , restrictions on lower-strength doses have been removed to allow dispensing from pharmacies, and prescribing guidelines introduced.

The operations of

PHARMAC considered a number of important policy issues during the year and continued its efforts to improve quality and efficiency.

Hospital drugs

Policy issues

Compassionate supply

Guidelines have been developed, and are being discussed with pharmaceutical companies, on the complimentary supply of new, unlisted, drugs. This is an important ethical issue because there can be problems when a supplier withdraws the complimentary supply. The Researched Medicines Industry Association of NZ lnc has been invited to adopt the guidelines. Meanwhile PHARMAC has had a positive response from some companies.

Drugs for the treatment of diseases managed largely by Crown Health Enterprises (CHEs) are not part of PHARMAC's brief. These include paclitaxel and G-CSF (Neupogen). PHARMAC has supported hospital pharmacists in efforts to encourage information transfer between CHE medical committees.

Specialist recommendation

To overcome a lack of clarity in Retail PhannacySpecialist and Hospital Pharmacy-Specialist prescribing, PHARMAC introduced clearer definitions of what constitutes a specialist consultation, along with more precise rules and procedures.

Expensive medicines

A process was developed for accurate assessment of need and equitable access by patients to drugs classified as "very expensive" (more than $25,000 a year per patient) . This involves specialists, PTAC and the RHAs. Outcomes will be improved targeting and consistency of access across RHAs.

Prescribing rights for non-specialists

A policy was developed with RHAs to provide access by doctors with special skills to specialist drugs. The appropriate drugs will be defined by PTAC and the RHAs are developing decision criteria on which practitioners should be included. Doctors in palliative care may be eligible shortly.

Exceptional circumstances

A policy was developed with RHAs for enabling access to a subsidy for drugs on a case-by-case basis where there is a proven need and the circumstances are exceptional.

Applications for listing

PHARMAC considered 79 applications, listed 54, declined 20 and de-listed one. Four were withdrawn by suppliers.

PHARMACEUTICAL MANAGEMENT AGEr\CY LTO

Applications considered and decided

Years ended 30 June

Number Total applications Listed Declined Withdrawn De-listed

Cumulative annual savings by decision type

Estimates for years ended 30 June, before GST.

Number

1995

79 54

1994

72 52 20 0 0

1995

_ $500,000 $500,000 $19,000,000

1994

($200 ,00QL

$100,000

-~-

New chemicals New presentations New products Reviews Total ~vi~

Two thirds oJ applications resulted in lisTing on the Pharmaceutical Schedule.

_ $1 ,200l!0~ $5,300,00~ _ _$1 , I00,000 _ $25,300,000 $2,200,000

Most savings callle Fom the introduction oJ price competition resultingFolllthe listing of ne>!' products.

Application decisions by type

Years ended 30 June

Number Chemical not currently listed De-restriction or easing of restriction Presentation (line extension) Significant price increase Generic or new brand name

1995

11 5 21

1994

25 7 17

Streamlining the processes

A goal of PHARMAC is to streamline its decision and review processes. These processes include formal quality control procedures for dec ision papers presented to the PHARMAC Board, the main requirements being that appropriate consultation takes place and that sufficient time is available for papers to be peerreviewed. Other requirements are that papers be signed off by managers, that there be written confirmation of consultation, advice to RHAs of Board agendas at least a month prior to meetings, and distribution of full agendas to RHAs, whenever poss ible, at least a week prior to meetings.

Near/I' half oJ all applications ill 1995 were Jar generics.

Pharmaceutical Schedule

The Schedule was re-printed three times during the year, and 12 monthly Updates distributed. The readability and accessibility of the Schedule will be further improved and the quality of information enhanced by the inclusion of average daily cost data from December 1995. The Schedule is distributed free to about 10,000 medical practitioners, pharmacists, medical libraries, professional bodies, and user and support groups, and offered for sale to a small subscription list, including drug suppliers.

Widespread consultation

[n taking decisions on the Schedule, PHARMAC seeks medical and commercial data and views relevant to the drug or drug famil y under review. This includes release of the views of PTAC to doctor groups and drug companies with invitations to comment; and a process through which the applicant is given an opportunity to comment both on the recommendation ofPTAC and the proposed decision of PHARMAC.

Financial impact of PHARMAC decisions

PHARMAC decisions resulted in RHAs spending more than $25 million in the year less on pharmaceutical benefits than would have been spent if past trends continued. The reduction came mainly from encouraging price competition, and by reviewing the terms and conditions of subsidy of products already on the Schedule. Details by type of product are:

Open communication

PHARMAC believes that a free, fair and open flow of information will play a vita l role in the balancing of health needs and costs. Newsletters are usually enclosed with the mailing of Updates to the Schedule. These provide information on the outcomes of reviews, new drugs listed, changes to prescribing guidelines, the lifting of restrictions on prescribing, and product price and subsidy changes.

Complementing the newsletters are contributions to specialist publications such as GP Weekly, the New Zealand Medical Journal, Pharmacy Today, patient magazines, and releases to the daily media where the information is of widespread interest, as for example, with the decision to subsidise asthma spacers for young children. PHARMAC also seeks open dialogue with all participants in the health care industry. In the last year, it attended the annual conference of the New Zealand Hospital Pharmacists ' Association , and met regularly with prescriber groups such as the New Zealand Medical Association , Royal New Zealand College of General Practitioners, the New Zealand Genera l Practioners' Association, the Paediatric Society, diabetes specialists, groups of nurse educators, specialist caregivers, nurses and prescribers, patient support groups such as the Asthma Foundation , Herpes Foundation, and the Mental Health Coalition, and many others. PHARMAC's relationships with the pharmaceutical supply industry were sometimes difficult, notwithstanding a desire on PHARMAC's part for dialogue and negotiation in pursuit of win-win type solutions. With some companies, the relationship was more constructive than with others.

and a number of staff continued post-graduate education. All staff attended training sessions with the Ombudsman's Office on PHARMAC's responsibilities under the Official Information Act. Several staff attended short courses to update their computer and other technical skills, and all therapeutic group managers were trained in the principles of judicial review and procedural law.

Litigation

In June 1995 , the Researched Medicines Industry Association of NZ Incorporated (RMI) and three pharmaceutical manufacturing and distributing companies, associated as the Independent Pharmaceutical Manufacturers Association , filed a claim with the High Court against PHARMAC and the four RHAs. The claim seeks relief on a variety of grounds for alleged actions by PHARMAC in contravention of various statutes and regulations. PHARMAC believes the claim has no merit and intends to vigorously defend it. PHARMAC has also filed claims against the RMI and Adis International Limited for alleged publication of misleading information and contempt; and it is challenging applications for patent extensions for ranitidine (Zantac) and omeprazole (Losec) .

Personnel and training

To ensure quality output at optimum efficiency, training is a priority. A workshop was held with PTAC to improve skills in critical appraisal of medical literature (a core skill in the assessment of pharmaceuticals),

Financial performance

PHARMAC completed the year slightly over budget, despite incurring significant un-budgeted legal costs. The following is a breakdown of costs.

The annual cost of PHARMAC

Years ended 30 June

1995

Staff

--- ---co~ (includes Eir~or's and profe~onal

~-~-

1994 665,000 563,000 532,000

---- ------- ---

~~-

fees) ~

--------

804,000 575,000 1,047,000

------Con~ti~ servi~s Ji'lcJ'1.des leg~.f~s!R.

Office costs (includes depreciation *, ren~ phones,library, purchase of data)

~---

general consulting, audit fees, HRM and accounting)

Schedul':.Eroduction (printing and postage __'y-_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _26 -'-00 _ _ on ") _ _0 , _ _0 217,000 Total cost $2,686,000 $ 1,977,000

* At balance dale. PHARMACs fixed assels comprised $229.000 of office alld computer equipmenl,filmilllre alld fill ings.

Th e major item oJ expenditure in 1995 was il1 Jees paid Jar advice on medical, pharmacological, legal and communications issues.

PI IARMAC EUTICAL M ANAGe M ENT AGENCY I:J D

Drug groups by subsidy cost

British National Formulary classification Year ended 30 June 1995 Cost before GST in year

$57,100,000 $56,500,000 $45,100,000 $38,800,000 $34,800,000 $33,000,000 $23,100,000 $21,900,000 $21 ,300,000 $18,900,000 $15,100,000 $14,800,000 $13,000,000 $1 1,500,000 $10,100,000 $9,200,000 $9,100,000 $9,100,000 $8,900,000

Proportion oftotal cost

9.50% 9.40% 7.50% 6.50% 5.80% 5.50% 3.80% 3.70% 3.60% 3.20% 2.50% 2.50% 2.20% 1.90% 1.70% 1 .50% 1.50% 1 .50% 1.50% 1.50% 1.40% 1.40% 1.20% 1.10% 1.00% 1.00% 1.00% 0.80% 0.70% 0.70% 0.70% 0.70% 0.60% 0.60% 0.50% 0.50% 0.50% 0.50% 0.40% 0.40% 0.40% 0.40% 0.40% 0.30% 0.30% 0.30% 0.30% 0.30% 0.30% 0.30% 4.70%

Antihypertensive drugs Corticosteroids - respiratory system Nitrates and other vasodilators, and calcium channel blockers Antibacterial drugs Ulcer-healing drugs Bronchodilators Antidepressant drugs Drugs used in rheumatic diseases and gout Beta-adrenoceptor blocking drugs Analgesics Drugs used in diabetes Contraceptives Drugs used in the treatment of hyperlipidaemia Sex hormones Drugs acting on the nose Topical corticosteroids Monitoring and diagnostic agents (blood plasma or sera) Antiepileptics Anti-infective skin preparations Drugs used in Parkinsonism and related disorders Drugs affecting the immune response Prophylaxis of asthma Sex hormones and antagonists in malignant disease Preparations for acne Laxatives Drugs used in psychoses and related disorders Antiviral drugs Diuretics Hypothalamic and pituitary hormones and anti-oestrogens Treatment of chronic diarrhoeas Treatment of glaucoma Vitamins Anti-arrhythmic drugs Hypnotics and anxiolytics Corticosteroids - endocrine system Foods for special diets and nutritional support Drugs used in other musculoskeletal disorders Allergic disorders Drugs used in anaemias Emollient and barrier preparations Antacids Antifungal drugs Drugs used in nausea and vertigo Minerals Preparations for psoriasis and eczema Treatment of vaginal and vulval conditions Drugs affecting intestinal secretions Electrolyte and water replacement Antiplatelet drugs Rectal and colonic drugs Other drugs GST

---

$8,900,000 $8.500,000 $8,100,000 $7,000,000 $6,700,000 $6,000,000 $5,900,000 $5,800,000 $4,900,000 $4.400,000 $4.300,000 $4,200,000 $4,100,000 $3,600,000 $3 ,300,000 $3,200,000 $2,900,000 $2,900,000 $2,800,000 $2,600,000 $2,300,000 $2,300,000 $2,300,000 $2,200,000 $2,000,000 $1,900,000 $1 ,700,000 $1,700,000 $1,600,000 $1 ,600,000 $1,600,000 $27,900,000 $74,900,000 $674, I 00,000

Total cost in year including GST

Top 30 drug groups by increase in subsidy cost

British National Formulary classification Year ended 30 June 1995

Antihypertensive drugs Antidepressant dru~ Nitrates and other vasodilators, and calcium channel blockers Drugs used in the treatment of hyperlipidaemia Analgesics Antibacterial drugs Corticosteroids - respiratory system Antiviral drugs Bronchodilators Sex hormones

Dru~ used in diabetes Antiepileptics Anti-infective skin preparations Topical corticosteroids Monitoring and diagnostic agents (blood plasma or sera)

Cost increase before GST in year

$6,700,000 $5,000,000 --$3,300,000 $2,700,000 $2,600,000 $2,600,000 $2,000,000 $1,600,000 $1,600,000 $1,600,000 $1,400,000 $1,300,000 $1, I 00,000 $930,000 $880,000 $880,000 $840,000 $750,000 $720,000 $580,000 $500,000 $470,000 $440,000 $300,000 $290,000 $270,000 $260,000 $260,000 $260,000 $200,000 $3,100,000 $15,600,000 $29,700,000 $3,700,000 $33,400,000

Proportion of total cost

9.50% 3.80% 7.50% 2.20% 3.20% 6.50% 9.40% 1.00% 5.50% 1.90% 2.50% 1.50%1.50% 1.50% 1.50% 1.10% 0.70% 0.70% 3.60% 1.40% 1.20% 0.40% 1.00% 0.50% 0.60% 1.00%

Proportion of total cost increase

22.40% 16.90% 11.20% 9.10% 8.80% 8.80% 6.80% 5.30% 5.30% 5.30% 460% 4.20% 3.80% 3.10% 3.00% 3.00% 2.80% 2.50% 2.40% 2.00% 1.70% 1.60% 1.50% 1 .00% 1.00% 0.90% 0.90%

Preparations for acne Vitamins Treatment of chronic diarrhoeas Beta-adrenoceptor blocking drug~ Drugs affecting the immune response

- - -

Sex hormones and antagonists in malignant disease Drugs used in anaemias Laxatives Allergic disorders Anti-arrhythmic drugs Drugs used in psychoses and related disorders Antifungal drugs Corticosteroids - endocrine system Foods for special diets and nutritional support Minerals Other increases Decreases Net increase GST

0.40% -

0.50% 0.50% 0.30% 12.51% 14.49%

0.90% 0.90% 0.70% 10.40%

Total increase in cost in year including GST

PHARMACElITlCAL MANAGEMENT AGENCY L TD

Metadata

Title

Annual Review 1995

Abstract

PHARMAC III Pharmaceutical Management Agency Ltd for the year ended 30 June Treating more patients. Slowing budget growth. PHARMAC (Pharmaceutical Management Agency Limited) was established in mid-1993 to manage the national Pharmaceutical Schedule on behalf of the four RHAs (Regional…

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