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

their clinical circumstances would differ from all others seeking that particular
treatment. It appears PHARMAC is recommending an abolition of the ‘10
cases’ rule to determine rarity and instead are recommending that clinical
uniqueness be the entry criteria. PHARMAC states that in order to meet its
statutory obligations, PHARMAC will assess whether they should fund
treatments for people in this position. The scheme makes no reference to the
principles of distributive justice.
The details of how UCC claims will be assessed have not been determined yet,
but it is likely that PHARMAC will appoint a Panel to decide on each claim
against its nine decision making criteria. Unless there is explicitness as to why
the Panel reaches their decisions and openness in communicating these
decisions to the claimants and the public, little will have changed from the
current operation of the Community Exceptional Circumstances policy.
The UA scheme is a proposed pathway for individuals with serious conditions
who might experience a rapid deterioration in their health or lose the opportunity
for a quality of life improvement unless the treatment is provided. The patients
in this category would be part of a group of patients with similar conditions
where the treatment is potentially life-saving. It is likely that the treatment being
applied for under the UA would also be subject to a full Schedule listing
approval process. In these terms, the UA is to manage the requests for urgent
treatment before the drugs can be listed on the Schedule. If the drug is
assessed for listing on the Schedule and declined, then the UA subsidy for
individuals who have been granted treatment under UA would be discontinued.
PHARMAC state that this is because a patient in this position would be in no
different position than a patient waiting for the Schedule approval for any other
drug.
PHARMAC also proposed to set out the prerequisite criteria before an
application can even be considered under the three new proposed schemes.
Meeting the prerequisite conditions would not guarantee the approval of the
claim; it simply means that the claim would be passed to the relevant panel for
assessment.
In future, PHARMAC will not consider any application for UCC if the drug in
question is pending a decision for listing on the Pharmaceutical Schedule.
213