How does the operation of PHARMAC's 'Community Exceptional ...

Q Be a voice for the family?
A Yes, I was someone that they could talk to… to see where the
application was at. But I was sort of managing political risk as well,
as well as financial risk.
Q … what was the political risk?
A Well if it gets out into the media… case management required
sensitivity when dealing with patients. If not managed well, the
potential for adverse publicity was high.
Q Then what would happen?
A Adverse publicity around what can be funded and what can’t be
funded. It would have to be managed…as long as it’s managed
properly it’s okay…and that’s what I used to be able to do, because
we had very clear criteria for Exceptional Circumstances, I was able
to explain to the patient or the family member if they had to be
declined, why they’d been declined on the criteria and they could
accept that.
Q Over the years you must have managed many hundreds of these
applications. Is that right?
A Well…hundreds or possibly thousands…I couldn’t be that sure… I
managed a great many claims that’s for sure. (Interviewee D)
Related to the issue of the patient’s ability to pay, as discussed with ‘C’, it was
clear that the administrator of the scheme had a very different view. This is
confusing because ‘C’ and ‘D’ worked closely together. On the point of the
affordability criteria, this is what interviewee ‘D’ had to say.
For exceptional circumstances does also involve the ability to
pay...were they were financially able to pay?
I pursued this question with ‘D’, to check that the financial affordability criteria
really existed.
Q So if they were financially able to pay, you are saying that a
Community Exceptional Circumstances claim wouldn’t pay for it?
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