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

Community Exceptional Circumstances decisions are all managed by
PHARMAC and are finally arbitrated by the PHARMAC board.
For this reason, PHARMAC was found to be placed in a conflicted interest in
any review or investigation of its own actions. These conflicts (or even
apparent conflicts) were described as PHARMAC being the arbiter on its own
processes, particularly because cost containment is the strong mandate in all
decision making. External review of the decisions would give unsuccessful
claimants an opportunity to argue for the reversal of PHARMAC’s decisions.
This proposal was strongly rejected by PHARMAC for two reasons. Firstly,
PHARMAC stated that their Board was equivalent to a Citizens Council
because it was appointed by the Minister of Health. Secondly, PHARMAC
stated that it could not tolerate external review of its decisions because such a
review (even advisory) would put at risk its financial performance for which it
was accountable to Parliament.
The NZORD interviewee suggested that PHARMAC should significantly
increase the budget for Community Exceptional Circumstances. They
suggested that the budget should be increased from $3 million to $8 million to
position New Zealand’s scheme in line with the funding levels available for rare
diseases to the Australian Benefits Scheme. PHARMAC has accepted this
advice and announced an increase in funding for the new Exceptional
Circumstances scheme by increasing the available funding to $8 million.
The PHARMAC announcement of increased funding may not necessarily assist
NZORDs members to get access to the medicines they are applying for. This is
because the increase in funding also comes with a loosening of the decision
making criteria under the Named Patient Pharmaceutical Assessment scheme,
and it is probable that many more applications will now be received and
approved for non-NZORDs members increasing the competition for the larger
amount of funding.
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