Navigating the Pharmaceutical Benefits Scheme: federal versus state government funding for high-cost medicines – a problem for public hospitals.

ABSTRACT

The funding of medication supply in Australian public hospitals is divided between the federal government's Pharmaceutical Benefits Scheme (PBS) and thestate or territory government who pay for the remaining medications not covered under the PBS. For some high-cost medications, such as the monoclonal antibody blinatumomab, the current criteria for PBS funding in public hospitals are challenging. The strict requirement for inpatient admission, due to the risk of potentially serious adverse effects, alongside a lack of PBS reimbursement, while a hospital inpatient, may result in the state bearing the cost. A retrospective review of five patients receiving blinatumomab at our hospital found that, on average, patients remained inpatients for longer than that stipulated to meet PBS funding criteria, predominantly due to adverse effects associated with the medication. This resulted in the state government paying for the medication in full. The upcoming National Medicines Policy review should address the increasing complexity of new medications and their access and funding.