Abstract
Background
Despite being relatively low in Aotearoa New Zealand compared to similar health systems such as Australia and England, prescription co-payments are seen as a significant barrier to accessing the critical pharmaceutical care offered in pharmacies and are the source of much political debate. To remain operating, pharmacies must also be profitable; a variety of strategies have been seen to attract customers. Some pharmacies paid the prescription co-payments on people’s behalf and used the offer of free prescriptions to attract patronage to their pharmacies before the central government decided to remove prescription co-payments universally. When the government changed, and co-payments were reintroduced, some pharmacies also reinstated waivers. These are all business and political decisions surrounding prescription co-payments, with little understanding of the effect prescription co-payments have on people's use of medicine.
Aim
To investigate the impact of prescription co-payments on people's choice of community pharmacy and how that choice influences their medicine use in Aotearoa New Zealand.
Methods
This thesis consisted of five discrete but interconnected projects:
• A systematic review to compare medication adherence between the users of independent and chain pharmacies in other countries.
• A nationwide retrospective observational study describing the consumer profiles of different community pharmacies in New Zealand.
• A methodology study to report how focus groups and thematic analysis can be used to develop attributes and their levels and frame a discrete choice experiment (DCE).
• A DCE to determine New Zealanders' preferences for community pharmacies when collecting prescriptions.
• A retrospective observational study to compare the rates of adherence to diabetes medications between users of different types of community pharmacies in New Zealand.
Results
The systematic review revealed no significant difference in medication adherence between independent and chain pharmacies internationally. However, lower-income individuals, those with a higher medication burden, and older adults showed a preference for independent pharmacies and had higher medication adherence rates when doing so. The consumer profile analysis indicated that independent pharmacies in New Zealand serve an older demographic with fewer Asian users, while hybrid pharmacies cater more to Pacific Peoples and those from high-deprivation areas. These findings provided a baseline for understanding how the removal of prescription co-payments might shift consumer behaviour. A method showing future researchers how to use focus groups and thematically analyse the discussions to develop their DCE was presented. Location, prescription co-payments, customer service, wait times, availability of car parking, and proximity to nearby businesses were the most important attributes for New Zealanders when deciding where to collect a prescription. The DCE found that location and free prescriptions were the most attractive attributes for community pharmacies. Three market segments that place an even greater emphasis on prescription co-payments, convenience, or customer service were uncovered but could not be causally associated with demographic information. The retrospective observational study showed that users of corporate and hybrid pharmacies, which do not charge prescription co-payments, are slightly less adherent compared to those using independent pharmacies. Mail-order pharmacy users exhibited the highest adherence rates, while mixed pharmacy users showed the lowest. These results suggest that factors other than prescription co-payments, such as service quality and convenience, may play a more significant role in medication adherence.
Conclusions
This thesis highlights the significant role prescription co-payments play in people's choice of community pharmacy and how they influence medication adherence. While the strategy of paying prescription co-payments on behalf of patients is highly effective in attracting patients, it has largely been employed by corporately owned pharmacies and hybrid pharmacies, primarily in the Auckland region. As a result, prescription co-payments are inequitably affecting people’s ability to access medicine as these types of pharmacies are not available to all. However, the trend of adopting lower-cost models may reduce the quality of care these pharmacies deliver, as evidenced by the lower rates of adherence being seen by the users of pharmacies offering free prescriptions. Policy decision-makers must decide if they are comfortable with this potential impact when considering future decisions regarding prescription co-payment policies in Aotearoa New Zealand's primary healthcare system.