Why some medicines are only funded for particular groups
Some medicines treat many illnesses and how they are used is the decision of the health professional writing the prescription. When it comes to funding medicines, we want effective treatment to be available to the people who need it most. In some cases, targeting can help us to identify the people who will benefit the most from a medicine.
In the same way we assess each medicine to decide if it is suitable for funding, we must also assess which patients might best benefit from that medicine. If people who won’t benefit from the medicine have it provided, then money is wasted and that means there is less funding available for other medicines or health services.
How do we target medicines?
Some of the ways we may target medicines:
This requires a prescriber to write on the prescription that their patient meets the criteria for full subsidy. This can be used where a treatment (such as antibiotics) is required urgently and there isn’t time to apply for a Special Authority approval.
This is our most frequently used targeting tool. Usually, the published Special Authority criteria define the clinical circumstances of patients who can receive funding for the medicine. People may first be required to try a less expensive medicine or the medicine may need to be prescribed by a particular type of health practitioner.
Special Authority applications are processed by the Ministry of Health’s Sector Operations Group. We’ve worked with them to improve the Special Authority process, and now the majority of Special Authority applications are processed electronically, usually while the patient is still with the prescriber.
Named Patient Pharmaceutical Assessment (NPPA)
NPPA is a mechanism to give individual named patients access to medicines they need, but which aren’t funded on the Pharmaceutical Schedule. PHARMAC has reviewed its NPPA policy to assess whether it was effective. This process, which involved public consultation, led to PHARMAC revising its NPPA policy in 2015 to make it clearer and easier to interpret and apply. The NPPA policy now sits inside a broader Exceptional Circumstances Framework which also includes other exceptions such as waivers for medicine funding restrictions. The NPPA application process was also simplified and an online form is now available to help make the application process easier. Applications for assessment are made by a person’s prescriber, including those in the community and public hospitals. Decisions are made using PHARMAC’s Factors for Consideration, after obtaining clinical advice.
Special Access Panels
Some pharmaceuticals are very expensive, and to help ensure these are appropriately targeted, PHARMAC manages panels of expert doctors to apply the Special Authority criteria on which patients can access treatments. Panels are currently maintained for:
- Cystic Fibrosis
- Gaucher treatment
- Multiple Sclerosis treatment
- Pulmonary Arterial Hypertension
- Haemophilia treatments
- Hepatitis C treatment
- Named Patient Pharmaceutical Assessment Panel
Around 4000 panel applications are received each year.
Biomarkers allow clinicians to dive deeper into a patient’s illness to fully understand the often complex and complicated condition they have. In some situations biomarker testing can provide a mechanism to identify which patients would most likely benefit from a particular treatment and also which ones wouldn’t. When patients are identified in this way it provides a much clearer picture of the potential benefits and risk of treatments for certain patients and in doing so, may give PHARMAC more assurance of its value for these patients.
In some cases the availability of a validated biomarker and test can be the difference between a new treatment being funded or not.
Last updated: 26 August 2020