How New Zealand has contained expenditure on drugsBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2441 (Published 18 May 2010) Cite this as: BMJ 2010;340:c2441
All rapid responses
I congratulate Scott Metcalfe on his remarkable achievement in
maximising New Zealand healthcare outcomes from the given Community Drug
budget. Welsh GPs are incentivised to do much the same, with far less
constraint, and unsurprisingly, far less success.
Of the nine published criteria, might I ask if criterion 9 was ever
"Such other criteria as PHARMAC thinks fit (after appropriate
I am a GP in a Welsh Prescribing Incentive Scheme. I hold no shares, but have no idea whether my Bank and Pension fund managers invest in Pharmaceuticals.
Competing interests: No competing interests
Clarifications on How New Zealand has contained expenditure on drugs
We welcome Cummings et al’s assessment of New Zealand’s medicines funding . It provides a broadly accurate reflection of this country’s attempts to achieve the best health gains from pharmaceuticals within available funding. However, to complete the record, we offer the following corrections and clarifications.
Firstly, with the reference pricing of ACE inhibitors in 2002, no significant associated change in blood pressure control was found [2,3], at least short term in the context of more intensive dedicated monitoring. PHARMAC funded two doctor visits per patient to assess, switch and then review. What in fact the first retrospective study  reported was patients having any change in prescription within six months of the initial switch (the working definition of “unsustained”); this included attempts to back-titrate doses, and ironically any improvements in blood pressure. The second study  reviewed almost 100,000 patients during the change process and reported overall a small improvement in mean blood pressures.
Secondly, the statement that spending on statins would have meant not spending on other drugs at the time cites incorrect clinical indications and is misattributed. The correct citation was Metcalfe & Moodie 2002 , which catalogued potential opportunity costs, including cyclosporin and tacrolimus, neither of which is indicated nor funded for treatment-resistant epilepsy.
Thirdly, PHARMAC’s decisions about trastuzumab (Herceptin) specifically related to its adjuvant use in early HER2-positive breast cancer; it was funded already for metastatic disease. Adjuvant trastuzumab can be given in two main sequences: concurrently with, or sequentially after, other chemotherapy. Issues around sequencing were important to those decisions, with the sequential 12 month course (the sequence applied for funding in New Zealand) being probably less effective than concurrent 12 months . These differential effects for sequencing also affected the evidence base for the 12 month courses [6-8]. PHARMAC initially decided not to fund the sequential 12-month course, then later decided to fund the concurrent 9-week course. The correct reference for PHARMAC’s early reasoning is the earlier Metcalfe/Evans/Priest article . Controversy courted both sides of the debate, with at least one key Women’s Health Group supporting PHARMAC’s decisions because of uncertainties . New Zealand now funds all of the distinct concurrent 12-month, sequential 12-month and concurrent 9-week courses .
PHARMAC has responded extensively to the criticisms  about the quality of care thought to result from PHARMAC decisions [11-35]; links to the many responses are available on the PHARMAC website at http://www.pharmac.govt.nz/healthpros/ourviews/opinion.
Chief Advisor Population Medicine
Cumming J, Mays N, Daubé J. How New Zealand has contained expenditure on drugs. BMJ 2010;340:c2441. http://www.bmj.com/cgi/content/extract/340/may18_1/c2441
Maling T, Andersen V, Norris P, Cumming J, Arroll B, et al. Evaluation of the Implementation and Sustainability of the ACE Inhibitor Reference Pricing Initiative. Wellington Drug Utilisation Research Unit, University of Otago Wellington School of Medicine, Wellington, 2003. Report commissioned by PHARMAC, corrected version.
Perkins E, Dovey S, Tilyard M, Boyle K, Penrose A. A change management strategy to modify ACE inhibitor prescribing. Dunedin RNZCGP Research Unit, 1999.
Metcalfe S, Moodie P. More about cardiovascular disease and lipid management in New Zealand. NZ Med J 2002;115(1163).http://www.nzma.org.nz/journal/115-1163/203/
Metcalfe S, Burgess C, Laking G, Evans J, Wells S, Crausaz S. Trastuzumab: possible publication bias. Lancet 2008;371:1646-8. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2808%2960706-0/fulltext. (further detail is contained n the Accepted Authors Manuscript on the PHARMAC website at http://www.pharmac.govt.nz/2008/05/23/Accepted%20Authors%20Manuscript%2008CMT0415MetcalfeTrastuzumabDMc.pdf ).
PHARMAC. Herceptin – a summary of the evidence at August 2008.http://www.pharmac.govt.nz/2008/08/07/Herceptin%20Aug%2008%20clinical%20data%20summary.pdf at http://www.pharmac.govt.nz/media/herceptin
Metcalfe S, Evans J, Priest G. PHARMAC funding of 9-week concurrent trastuzumab (Herceptin) for HER2-positive early breast cancer. N Z Med J. 2007 15 June;120(1256). http://www.nzma.org.nz/journal/120-1256/2593
Metcalfe S, Evans J. PHARMAC responds on Herceptin assumptions and decisions. NZ Med J 2007;120:2692. http://www.nzma.org.nz/journal/120-1260/2692/
Women's Health Action Trust. Happily ever after with Herceptin. December 2006 http://www.womens-health.org.nz/index.php?page=happily-ever-after-with-herceptin
PHARMAC. Approval of proposal to amend the access criteria for trastuzumab (Herceptin) in the Pharmaceutical Schedule, 4 June 2010. http://www.pharmac.govt.nz/2010/06/04/2010-06-04%20Notification_%20approval%20of%20proposal%20to%20list%2012%20months%20trastuzumab.pdf
Moodie P. Pharmac drug decisions based on price and quality. NZ Herald, 26 May 2004 http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=3568287&pnum=0
- Moodie P, Metcalfe S, McNee W. Response from PHARMAC: difficult choices. NZ Med J 2003;116:361. http://www.nzma.org.nz/journal/116-1170/361/
- Moodie P, McNee W, Metcalfe S. PHARMAC welcomes debate. NZ Med J 2005;118:1572. http://www.nzma.org.nz/journal/118-1218/1572/
- Metcalfe S, Moodie P, McNee W. PHARMAC and tobacco control in New Zealand: two licensed funded options are already available (with responses by Holt et al and the Editor). NZ Med J 2005;118:1544. http://www.nzma.org.nz/journal/118-1217/1544/
- Metcalfe S, Moodie P. More on PHARMAC and tobacco control in New Zealand. NZ Med J 2006;119:1837. http://www.nzma.org.nz/journal/119-1228/1837/
- McNee W, Moodie P, Schmitt S, Dick A. PHARMAC’s response to Tim Blackmore on the sole supply of influenza vaccine. NZ Med J 2005;118:1601. http://www.nzma.org.nz/journal/118-1219/1601/
- Davies A, Metcalfe S, Moodie P, McNee W. PHARMAC responds to Stewart Mann on dihydropyridine calcium channel antagonists. NZ Med J 2005;118:1621. http://www.nzma.org.nz/journal/118-1220/1621/
- Metcalfe S, Moodie P, Davies A, McNee W, Dougherty S. PHARMAC responds on salbutamol. NZ Med J 2005;118:1644. http://www.nzma.org.nz/journal/118-1221/1644/
- Metcalfe S, Evans J, Moodie P. PHARMAC responds on long-acting insulin analogues. NZ Med J 2005;118:1716. http://www.nzma.org.nz/journal/118-1224/1716/
- Metcalfe S, Dougherty S. PHARMAC responds on long-acting inhalers for COPD. NZ Med J 2005;118:1743. http://www.nzma.org.nz/journal/118-1225/1743/
- Crausaz S, Metcalfe S. PHARMAC’s response on gemcitabine and transparency. NZ Med J 2005;118:1733. http://www.nzma.org.nz/journal/118-1225/1733/
- Metcalfe S, Moodie P, Grocott R, Wilkinson T. PHARMAC responds on TNF inhibitors for inflammatory arthritis. NZ Med J 2005;118:1799. http://www.nzma.org.nz/journal/118-1227/1799/
- Metcalfe S, Rasiah D, Dougherty S. PHARMAC responds on treatments for pulmonary arterial hypertension. NZ Med J 2005;118:1805. http://www.nzma.org.nz/journal/118-1227/1805/
- Metcalfe S, Crausaz S, Moodie P, McNee W. PHARMAC’s response on temozolomide and funding costly medicines that prolong life shortly. NZ Med J 2005;118:1806. http://www.nzma.org.nz/journal/118-1227/1806/
- Moodie P, Dougherty S. PHARMAC’s response on clopidogrel. NZ Med J 2006;119:1872. http://www.nzma.org.nz/journal/119-1229/1872/
- Metcalfe S, Wilkinson T, Rasiah D. PHARMAC responds on agents to prevent osteoporotic fractures. NZ Med J 2006;119:1895. http://www.nzma.org.nz/journal/119-1230/1895/
- Moodie P, Metcalfe S, Dougherty S. PHARMAC and EpiPen for anaphylaxis. NZ Med J 2006;119:2038. http://www.nzma.org.nz/journal/119-1236/2038/
- Grocott R, Metcalfe S, Moodie P. PHARMAC and erythropoietin for cancer patients. NZ Med J 2006;119:2039. http://www.nzma.org.nz/journal/119-1236/2039/
- Grocott R, Metcalfe S. Going against the flow: the impact of PHARMAC not funding COX-2 inhibitors for chronic arthritis. NZ Med J 2005;118:1690. http://www.nzma.org.nz/journal/118-1223/1690/
- Moodie P, Dougherty S, Metcalfe S. PHARMAC and statins—getting the best population health gains. NZ Med J 2006;119:2092. http://www.nzma.org.nz/journal/119-1238/2092/
- Metcalfe S, Moodie P. PHARMAC and statins—correction is needed. NZ Med J 2007;120:2453. http://www.nzma.org.nz/journal/120-1250/2453/
- Moodie P. PHARMAC responds on tolterodine for overactive bladder. NZ Med J 2006;119:1871. http://www.nzma.org.nz/journal/119-1229/1871/
- Metcalfe S, Evans J, Priest G. PHARMAC funding of 9-week concurrent trastuzumab (Herceptin) for HER2-positive early breast cancer. NZ Med J 2007;120:2593. http://www.nzma.org.nz/journal/120-1256/2593/
- Metcalfe S, Evans J. PHARMAC responds on Herceptin assumptions and decisions. NZ Med J 2007;120:2692. http://www.nzma.org.nz/journal/120-1260/2692/
- Baber WJ, Neeff M; Moodie P. Ciproxin HC eardrops application for funding—and response from PHARMAC. NZ Med J 2008;121:111-2. http://www.nzma.org.nz/journal/121-1281/3260/
Competing interests: No competing interests
Pharmac requires general practitioners to jump through some
irritating hoops [as an example, its change from the requirement that
medication normally be dispensed monthly to prevent waste and restrict
costs, to a requirement that medication normally be dispensed three-
monthly to reduce dispensing fees, with tedious requirements to authorise
more frequent dispensing] but it has saved New Zealand hundreds of
millions of dollars, in deciding on scientific and logical grounds which
drugs will be funded by the taxpayer.
Cummings et al have noted one of the dangers which Pharmac faces:
promises by each of the two main political parties, during election
campaigns, to fund specific drugs which have been promoted by special
interest groups. It is to be hoped that parties will not make a habit of
this unscrupulous and destructive ploy.
Government needs to be aware of another danger: "Big Pharma".
Pharmaceutical companies see their profits threatened by bodies such as
Pharmac, which are not restricted to making recommendations, but have the
power to make decisions about public funding of medications. They will,
as they have in other countries, attempt to use the present mania for free
-trade agreements to break down Pharmac's funding restrictions.
I am a general practitioner in New Zealand, so decisions of Pharmac have a direct effect on my prescribing.
Competing interests: No competing interests