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

with the reasons for their decisions, PHARMAC created frustration and a
perception that claimants had not been treated fairly.
Rasiah’s (2009) thesis stated that 84% of ‘Community Exceptional
Circumstances’ claims were unsuccessful and there was uncertainty for
physicians (and patients) about the outcome for claims. In Chapter 5,
interviewees reported that some doctors were able to ‘game’ the system and
gained an advantage for their patients over other doctors’ patients in similar
circumstances. The ‘Community Exceptional Circumstances’ policy was
described by interviewees as being an escape valve for PHARMAC and the
royal road for the 16% of claimants who were successful in their claims
(Rasiah, 2009).
PHARMAC’s rational and analytical approach relied heavily on medical opinion
about clinical effectiveness and on the economic evaluation by cost-utility
analysis. Theme 2 Inconsistently Applied Criteria showed that these two
criteria dominated decisions and at times were used as a proxy for budgetary
constraint by PHARMAC. Yet budgetary constraint of these claims is exactly
what PHARMAC needed to do to exercise its warrant under the governing
legislation.
In summarising the test-question against the data of the research, a Rawlsian
consideration of the advantaged and the disadvantaged has demonstrated that
Community Exceptional Circumstances policy is fair to the majority because
their pharmaceutical needs have generally been well met. However, the data
have shown that there is considerable unfairness to the disadvantaged few who
suffer rare diseases or whose needs are considered exceptional. Their
pharmaceutical needs cannot be met, primarily because of the high costs to
PHARMAC and the challenge to the general pharmaceutical provision.
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