Factors associated with prescribing costs: analysis of a nationwide administrative database

Objective

All health care systems in the world struggle with rising costs for drugs. We sought to explore factors impacting on prescribing costs in a nationwide database of ambulatory care in Germany. Factors identified by this research can be used for adjustment in future profiling efforts.

Methods

We analysed nationwide prescription data of physicians having contractual relationships with statutory health insurance funds in 2014. Predictor and outcome variables were aggregated at the practice level. We performed analyses separately for primary care and specialties of cardiology, gastroenterology, neurology and psychiatry, pulmology as well as oncology and haematology. Bivariate robust regressions and Spearman rank correlations were computed in order to find meaningful predictors for our outcome variable prescription costs per patient.

Results

Median age of patients and proportion of DDD issued were substantial predictors for prescription costs per patient in Primary Care, Cardiology, and Pulmology with explained variances between 41 and 61%. In Neurology and Psychiatry only proportion of patients with polypharmacy ≥ 2 quarters was a significant predictor for prescription costs per patient, explaining 20% of the variance. For gastroenterologists, oncologists and haematologists no stable models could be established.

Conclusions

Any analysis of prescribing behaviour must take the degree into account to which an individual physician or practice is responsible for prescribing patients' medication. Proportion of prescriptions/DDDs is an essential confounder for future studies of drug prescribing.

Physicians’ relationship with the pharmaceutical industry and its reflection in introduction of a new drug

Purpose

This study aims to examine the attitudes of physicians towards the pharmaceutical industry and investigates how these are reflected when a new drug is introduced.

Design/methodology/approach

The qualitative theme-interview study adopts the innovation diffusion perspective and is conducted with 22 general practitioners and specialists.

Findings

Physicians’ positive relationship orientation and active interaction can result in early adoption of new drugs with product advantage. In comparison, negatively oriented and passively interacting physicians will adopt a new drug later based on research evidence- and experience-based reasoning and opinions of their colleagues.

Research limitations/implications

The objective was to obtain a deeper understanding of the research themes. Further qualitative studies in different countries and health care environments with a larger sample size would improve generalizability of results.

Practical implications

It’s necessary to find an optimal win – win situation that fulfils both parties’ needs, while decreasing unnecessary and time-consuming marketing activities and avoiding waste of limited resources and allowing physicians to participate in activities that better serve their primary needs. Managers in pharmaceutical companies should ensure their sales representatives act in appropriate and professional ways, interact openly and reciprocally and provide accurate and objective information.

Originality/value

The study demonstrates that the physician–pharmaceutical industry relationship has developed from being ethically precarious and having non-professional related personal benefits, towards becoming a more sustainable collaboration. The mutually beneficial collaboration supports physicians’ professional development, enabling better patient care and relieving strain on limited resources.

Pharmaceutical policies: effects of financial incentives for prescribers

BACKGROUND

The proportion of total healthcare expenditures spent on drugs has continued to grow in countries of all income categories. Policy-makers are under pressure to control pharmaceutical expenditures without adversely affecting quality of care. Financial incentives seeking to influence prescribers' behaviour include budgetary arrangements at primary care and hospital settings (pharmaceutical budget caps or targets), financial rewards for target behaviours or outcomes (pay for performance interventions) and reduced benefit margin for prescribers based on medicine sales and prescriptions (pharmaceutical reimbursement rate reduction policies). This is the first update of the original version of this review.

OBJECTIVES

To determine the effects of pharmaceutical policies using financial incentives to influence prescribers' practices on drug use, healthcare utilisation, health outcomes and costs (expenditures).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (searched 29/01/2015); MEDLINE, Ovid SP (searched 29/01/2015); EMBASE, Ovid SP (searched 29/01/2015); International Network for Rational Use of Drugs (INRUD) Bibliography (searched 29/01/2015); National Health Service (NHS) Economic Evaluation Database (searched 29/01/2015); EconLit - ProQuest (searched 02/02/2015); and Science Citation Index and Social Sciences Citation Index, Institute for Scientific Information (ISI) Web of Knowledge (citation search for included studies searched 10/02/2015). We screened the reference lists of relevant reports and contacted study authors and organisations to identify additional studies.

SELECTION CRITERIA

We included policies that intend to affect prescribing by means of financial incentives for prescribers. Included in this category are pharmaceutical budget caps or targets, pay for performance and drug reimbursement rate reductions and other financial policies, if they were specifically targeted at prescribing or drug utilisation. Policies in this review were defined as laws, rules, regulations and financial and administrative orders made or implemented by payers such as national or local governments, non-government organisations, private or social insurers and insurance-like organisations. One of the following outcomes had to be reported: drug use, healthcare utilisation, health outcomes or costs. The study had to be a randomised or non-randomised trial, an interrupted time series (ITS) analysis, a repeated measures study or a controlled before-after (CBA) study.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed eligibility for inclusion of studies and risks of bias using Cochrane Effective Practice and Organisation of Care (EPOC) criteria and extracted data from the included studies. For CBA studies, we reported relative effects (e.g. adjusted relative change). The review team re-analysed all ITS results. When possible, the review team also re-analysed CBA data as ITS data.

MAIN RESULTS

Eighteen evaluations (six new studies) of pharmaceutical policies from six high-income countries met our inclusion criteria. Fourteen studies evaluated pharmaceutical budget policies in the UK (nine studies), two in Germany and Ireland and one each in Sweden and Taiwan. Three studies assessed pay for performance policies in the UK (two) and the Netherlands (one). One study from Taiwan assessed a reimbursement rate reduction policy. ITS analyses had some limitations. All CBA studies had serious limitations. No study from low-income or middle-income countries met the inclusion criteria.Pharmaceutical budgets may lead to a modest reduction in drug use (median relative change -2.8%; low-certainty evidence). We are uncertain of the effects of the policy on drug costs or healthcare utilisation, as the certainty of such evidence has been assessed as very low. Effects of this policy on health outcomes were not reported. Effects of pay for performance policies on drug use and health outcomes are uncertain, as the certainty of such evidence has been assessed as very low. Effects of this policy on drug costs and healthcare utilisation have not been measured. Effects of the reimbursement rate reduction policy on drug use and drug costs are uncertain, as the certainty of such evidence has been assessed as very low. No included study assessed the effects of this policy on healthcare utilisation or health outcomes. Administration costs of the policies were not reported in any of the included studies.

AUTHORS' CONCLUSIONS

Although financial incentives are considered an important element in strategies to change prescribing patterns, limited evidence of their effects can be found. Effects of policies, including pay for performance policies, in improving quality of care and health outcomes remain uncertain. Because pharmaceutical policies have uncertain effects, and because they might cause harm as well as benefit, proper evaluation of these policies is needed. Future studies should consider the impact of these policies on health outcomes, drug use and overall healthcare expenditures, as well as on drug expenditures.

Analysis of French generic medicines retail market: why the use of generic medicines is limited

The market share of generic medicines in France is low compared to other European countries. This perspective paper provides an overview of the generic medicines retail market in France and how the current policy environment may affect the long-term sustainability. Looking at the French generic medicines retail market and the surrounding regulatory framework, all conditions seem to be in place to create a healthy generic medicines market: the country has well-respected regulatory authorities, generic medicines enter the market in a timely manner and prices of generic medicines are competitive compared with other European countries. Despite the success of the demand-side policies targeted at pharmacists and patients, those targeted at physicians were less successful due to a lack of enforcement and a lack of trust in generic medicines by French physicians. Recommendations to increase the use of generic medicines in France round off this perspective paper.

Where a cheap medicine is not the same as a generic medicine: the Belgian case

Objectives

The aim of this article is to describe the experience with the Belgian policy that obliges physicians to prescribe minimum quota of cheap medicines and to document the outcomes of this policy using publicly available data.

Methods

Data were obtained from yearly feedback reports of the policy on the website of the Belgian third-party payer (RIZIV/INAMI), which were sent to all physicians. Data were derived from Farmanet, a database where all data of prescriptions of reimbursed medicines from all physicians in Belgium are collected.

Key findings

All groups of general practitioners, specialists and dentists reached their minimum percentages every year from 2006 until 2009. The percentage of cheap medicines (in defined daily doses) increased from 22.9% in January 2005 to 44.2% of all prescribed medicines in ambulatory care in December 2009. The percentage of generic medicines increased from 12.10% in 2004 to 24.03% of all prescribed medicines in ambulatory care in 2008. When a physician prescribed a cheap medicine, this was an original medicine whose price had dropped to the reference price level in 41.5% of cases in August 2009.

Conclusions

The policy of prescribing quota for cheap medicines was not only associated with increased prescribing of generic medicines during 2004–2008, but also increased prescribing of original medicines whose price had dropped to the reference price level. The potential for prescribing generic medicines has not yet been fully met in Belgium. Despite the success of the policy, adjustments are desirable, especially with respect to the broad definition of cheap medicines. Given the fact that all groups of physicians reached their minimum quota quite easily together with the increased possibility of prescribing cheap medicines due to the entrance of new, generic medicines, the government decided to raise the minimum criteria in 2011.

Pharmaceutical cost control in primary care: opinion and contributions by healthcare professionals

Background

Strategies adopted by health administrations and directed towards drug cost control in primary care (PC) can, according to earlier studies, generate tension between health administrators and healthcare professionals. This study collects and analyzes the opinions of general practitioners (GPs) regarding current cost control measures as well as their proposals for improving the effectiveness of these measures.

Methods

A qualitative exploratory study was carried out using 11 focus groups composed of GPs from the Spanish regions of Aragon, Catalonia and the Balearic Islands. A semi-structured guide was applied in obtaining the GPs' opinions. The transcripts of the dialogues were analyzed by two investigators who independently considered categorical and thematic content. The results were supervised by other members of the team, with overall responsibility assigned to the team leader.

Results

GPs are conscious of their public responsibility with respect to pharmaceutical cost, but highlight the need to spread responsibility for cost control among the different actors of the health system. They insist on implementing measures to improve the quality of prescriptions, avoiding mere quantitative evaluations of prescription costs. They also suggest moving towards the self-management of the pharmaceutical budget by each health centre itself, as a means to design personalized incentives to improve their outcomes. These proposals need to be considered by the health administration in order to pre-empt the feelings of injustice, impotence, frustration and lack of motivation that currently exist among GPs as a result of the implemented measures.

Conclusion

Future investigations should be oriented toward strategies that involve GPs in the planning and management of drug cost control mechanisms. The proposals in this study may be considered by the health administration as a means to move toward the rational use of drugs while avoiding concerns about injustice and feelings of impotence on the part of the GPs, which can lead to lack of interest in and disaffection with the current measures.

Are private physicians more likely to veto generic substitution of prescribed pharmaceuticals?

Physicians' decisions whether or not to veto generic substitution were analyzed using a sample of 350,000 pharmaceutical prescriptions from the county of Västerbotten, Sweden. Although generic substitution reforms have been introduced in many European countries and American states, this is to my knowledge the first study on this topic. The topic is important since physicians' decisions regarding generic substitution not only directly affect patients' and insurers' costs for pharmaceuticals, but also indirectly since more bans against substitution reduces price-competition between pharmaceutical firms. The primary purpose was to test if physicians working at private practices were more likely to oppose substitution than county-employed physicians working on salary. It was found that private physicians were 50-80% more likely to veto substitution. Also, the probability of a veto was found to increase as patients' copayments decreased. This might indicate moral hazard in insurance, though other explanations are plausible.

An overview of pharmaceutical policy in four countries: France, Germany, the Netherlands and the United Kingdom

The regulation of pharmaceutical markets is an important policy concern in many countries, and is generally undertaken with cost containment, efficiency, quality and equity objectives in mind. This article presents an overview of the demand-side and supply-side regulatory measures that have been introduced in four European countries, namely France, Germany, the Netherlands and the United Kingdom. More specifically, after considering some of the trends in pharmaceutical expenditure in these four countries over recent decades, the article considers the policies that have been introduced to influence patient demand, health care provider behaviour and the pharmaceutical industry. Since many of the policies are concurrently applied, it is difficult to assess the isolated impact of each, particularly because the effect of particular policies may often be country specific. However, it is clear that there is no over-riding perfect solution to balancing the cost containment, efficiency, quality and equity objectives in pharmaceutical policy. No one policy or policy combination is right for all countries, and different countries will need to meet their own objectives through policy approaches that reflect their own particular environment.