E-drug: Prescribe better - make more money (cont'd)
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Dear E-Druggers,
I read the e-drug contribution on Dutch insurers with interest.
Personally I think financial incentives are very powerful for changing
prescribing practices and collaboration with insurers may be the
way forward. The one thing that concerns me about this particular
initiative is that there seems to be no monitoring or assessment of
whether prescriptions conform to national guidelines; they only
seem to be assessing whether costs are saved. This means that
prescribing quality could actually deteriorate, rather than improve,
due to patients not being prescribed what they should be
prescribed, in order to save costs. It would be good if presciptions
could be monitored, and the results of this experiment reported
(internationally), in terms of changes in prescribing quality as well
as costs saved. I believe that there was some discussion on e-drug
some years ago on financial incentives and how they may affect the
rational use of drugs so it may be worth seeing what is in the
e-drug archives. Very little work has been published in this area.
Some examples of how financial incentives may affect the use of
drugs are as follows:
(1) Prescribers who earn money from drug sales (e.g. dispensing
doctors, prescribing drug sellers) prescribe more drugs, and more
expensive drugs, than those prescribers who don't.
(2) A flat prescription fee which covers all the drugs in whatever
quantities contained within a prescription leads to over-prescription.
Therefore user charges should be made per drug items, not per
prescription.
(3) Dispensing fees that are calculated as a percentage of the cost
of drugs encourage the sale of more expensive drugs. Therefore a
flat dispensing fee irrespective of the price of the drug is to be
preferred, although such a fee may lead to a price increase for
cheaper drugs.
(4) Patients prefer drugs that are free or reimbursed. If an insurance
system or government health system is set up such that only
essential drugs will be reimbursed, patients will pressure prescribers
to prescribe only from the reimbursable essential drug list; when
drugs are only reimbursed if the prescription conforms to standard
treatment guidelines, there may be even stronger pressure on
prescribers to prescribe rationally. On the other hand if the
insurance system is set up to save money and not on the basis of
providing quality care, then prescribing quality may deteriorate e.g.
an insurance system that only reimburses 3 days worth of any drug
including antibiotics.
(5) Strategies aimed solely at reducing drug costs and drug use may
not necessarily result in improved prescribing quality. For example,
in the Rand Health Insurance experiment, there was some evidence
that increased cost sharing (higher co-payments) resulted in the
reduction of appropriate as well as inappropriate use of drugs. On
the other hand a study in Nepal, showed that precribing quality was
significantly improved when fees per drug item (covering a full
course) were charged as opposed to a fee per prescription.
However it should be noted that these two studies are not
comparable. In the Rand Health Insurance experiment, level (not
type) of fee was compared whereas in Nepal the type (not level) of
fee was compared. References for these studies are as follows:
Foxman et al, "The effect of cost sharing on the use of antibiotics
in ambulatory care: results from a population-based randomised
controlled trial", J.Chron.Dis, 1987, vol.40(5), pp.429-437.
Holloway & Gautam, "The effects of different charging mechanisms
on rationa drug use in Eastern Nepal", 1997,
http://www.who.int/dap-icium/posters/4e2_Text.html
I would be interested to hear the views and experience of others on
this issue.
Kathy
Kathleen Holloway
Medical Officer for Policy, Access and Rational Use
Department of Essential Drugs and Medicines Policy
World Health Organisation, 20 Ave.Appia, Gen�ve 27, CH-1211.
Tel: +41 22 791 2336; Fax: +41 22 791 4167
email: hollowayk@who.int
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