MJA Vol 179 17 November 2003 544 VIEWPOINT The Medical Journal of Australia ISSN: 0025-729X 17 November 2003 179 10 544-545 ©The Medical Journal of Australia 2003 www.mja.com.au Viewpoint The current “Pharmaceutical Benefits Scheme (PBS) community awareness campaign” explicitly links the difficulties facing the PBS to patient behaviour and “waste”. The campaign suggests that patients are taking advantage of affordable access to prescription medicines, and emphasises that patient responsibility is “the prescription for a healthy PBS”. By neglecting to inform the public that the pressures facing the PBS also include doctors’ prescribing habits and intensive pharmaceutical industry marketing, the campaign has missed an opportunity to initiate a balanced and constructive debate about the future viability of the PBS. (MJA 2003; 179: 544-545) IT HAS BECOME SOMETHING of an axiom that increasing cost is endangering the Pharmaceutical Benefits Scheme (PBS), and that something must be done about it. Typically, policy responses have been to target the prescription end- user — the patient. Successive governments have increased patients’ out-of-pocket charges as a means of containing drug costs. The present federal Government, thwarted thus far by the Senate in its attempt to increase the patient co- payment, is trying an alternative — appealing to patients’ moral sensibilities rather than their hip-pocket nerve. The current “PBS community awareness campaign”, 1 an initiative of the National Strategy for Quality Use of Medi- cines (QUM) 2 has been launched at a reputed cost of $27 million through a nationwide advertising strategy. 3 The objective of informing the Australian public about the operation, strengths and costs of the PBS is laudable. However, the tone of the campaign is morally charged, with the suggestion that many Australian patients are not acting responsibly in their use of prescription medicines. The two main mediums of the campaign — a series of television advertisements and an information booklet — emphasise an association between patient behaviour, “waste”, and the increasing financial pressure on the PBS, a pressure which imperils the future viability of the scheme. It appears that patient responsibility is “the prescription for a healthy PBS”. As part of the National Medicines Policy, the strategy for QUM is underpinned by a set of principles, the first of which is “the primacy of consumers”. The strategy claims to recognise “the wisdom of consumers” and states “consumer involvement in all aspects of the Strategy is critical”. 2 Far from incorporating the wisdom of patients, the present campaign appears to selectively choose more extreme exam- ples of misuse of medicines to establish a moral position and place the responsibility for increasing prescription demand on patients. The campaign booklet states “some people like to get a prescription every time they visit a doctor”. This statement implies that patients drive the demand for prescriptions and that the low cost of prescription medicines promotes waste- ful behaviour. The campaign repeatedly advises patients to take note of the full cost of the prescription that is borne by the Scheme (this is now highlighted on prescription labels). With such information, patients can “use the PBS responsi- bly” and minimise “waste”. Patients are also exhorted to consider their need for repeat prescriptions, but are not advised of the dangers of stopping treatment for some serious disorders (eg, diabetes and heart failure). The National Medicines Policy document raises the con- cern that “easy access can work against the quality use of medicines”, offering the common anecdote of patients’ stock- ing up unnecessarily on prescription medicines “.. . because they are available free or at low cost”. While patients probably do initiate a certain amount of unnecessary prescription demand, the relationship of this to the cost of a prescription is not clear in the available evidence. 4 Further, there is no substantial evidence to show that such behaviour is common enough to be a major contributor to rising drug expenditure. The emphasis on patient responsibility reveals a conviction that prescription subsidy through the PBS results in signific- ant “moral hazard”. In other words, low out-of-pocket cost generates unnecessary prescription demand or “waste”. Arguments for the operation of a “moral hazard” rest not on direct observations of patient behaviour, but on studies of aggregate prescribing data. 5 Rather than drawing on the wisdom of patients, fluctuations in use of prescription medicines after changes to out-of-pocket costs are used to make inferences about patients’ motivations. Differences in rates of use of “essential” therapies compared with “discre- tionary” therapies are taken as proxies for “necessary” and “unnecessary” patient behaviours. 6 However, prescribing data cannot show whether the changes in pharmaceutical use reflect appropriate or inappropriate patient responses to increased cost; nor can they reveal the motives of patients who have received prescriptions. Increased demand when drugs are affordable does not itself mean that patients are using medicines unnecessarily. 7 The PBS community awareness campaign: how helpful is blaming patients? Evan Doran and David A Henry MJA Rapid Online Publication: 20 October, 2003 Department of Clinical Pharmacology, University of Newcastle, Newcastle, NSW. Evan Doran, PhD, Researcher; David A Henry, FRACP, Professor. Reprints will not be available from the authors. Correspondence: Professor David A Henry, Department of Clinical Pharmacology, University of Newcastle, Level 5, Clinical Sciences Building, Mater Misericordiae Hospital, Newcastle, NSW 2298. mddah@mail.newcastle.edu.au VIEWPOINT