E-drug: Prescribe better - Make more money
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Dear E-druggers,
The article below appeared today in the Dutch newspaper NRC
Handelsblad. As I thought it is on a very interesting development, I
took the trouble to translate it.
One of the interesting issues mentioned in the article is a Dutch
initiative that lasted for many years, in which pharmacists and
physicians met on a monthly basis to talk about therapeutic issues
(the so-called 'pharmaco-therapeutic interchanges'). It did
apparently little to change prescribing practices.
I wonder which other non-knowledge and non-regulatory based
experiences E-druggers have in changing prescriber behavior,
especially those initiated by health insurances. Copied as fair use.
Hilbrand Haak
Consultants for Health and Development
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Sleedoorntuin 7 tel: +31-71-523.2052
2317 MV Leiden fax: +31-71-523.3592
The Netherlands e-mail: haakh@compuserve.com
Visit CHD's website at www.chd-consultants.nl
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Family physicians can 'prescribe themselves rich' - 120 family
physicians in the Heerlen region (The Netherlands) participate in a
remarkable experiment. If they try to prescribe less - and cheaper -
medicines, they receive a bonus from the health insurer.
By Rentsje de Gruyter
HEERLEN, 4 August 2001. Is the struggle of Minister Borst
(Ministry of health) finally bearing fruit? Announced this week, 120
family physicians in the Heerlen region made a remarkable deal with
health insurer CZ. CZ will pay each physician the amount of Fl
7.500 (approx. US$ 3000) if they participate in the period July
2001 and January 2002 in an experiment to change prescribing
behavior, read 'if they prescribe less'. In addition, any amount that
is saved between FL 7,500 and Fl 30,000, is paid out in full to him.
From each guilder saved on top of 30.000 saved guilders, he will
receive 75 cents. The fewer drugs a physician prescribes (and/or
the cheaper they are), the more profitable it all becomes.
Although health minister Borst agreed with the experiment, the
Dutch Medical Association has serious objections. "Two things are
unfairly coupled here: the income of a physician, and his prescribing
behavior", says vice-president J. Blaauw, family physician in the
east of the country. "Taking into account the independence of
prescribers, those two should never be connected. Imagine you
have many elderly patients in your practice, who need a lot of
medicines. In those cases you would miss income, as you don't
make your expected cost reductions." The Dutch Association of
Family Physicians will ask its members (90% of all Dutch family
physicians) not to participate in this kind of experiments.
Insurer CZ does not believe that independence of physicians is at
stake. "If there is one real entrepreneur, then it certainly is the
family physician", according to a CZ representative. "Each family
physician runs his own business. And if it is true that we would
limit his freedom, then they certainly would not have agreed".
However, even physician B. de Wit, spokesperson of the 120
physicians who participate in the experiment, admits that something
is wrong. "Of course it is not a pure 'exchange'. Physicians should
prescribe appropriately, with or without getting additional pay in
exchange." According to de Wit, roughly half of the physicians
were initially against the agreement with CZ. But the physicians had
their own agenda. Just as de Wit, they have come to see the
additional pay as a 'compromise to salary negotiations'.
Throughout the Netherlands, family physicians have long decried
what they call 'ridiculously low' pay for evening-, night- and
weekend shifts. Through this back door possibility physicians from
Heerlen now get their compensation and consider it a 'sweetener'
from an insurer. The physicians say they are now 'holding their
breath' until 1 January, when reimbursement negotiations with
insurers start again. "If we have reached our objectives, we'll have
a strong position as a group", according to de Wit.
For the insurer, stakes are different. Since long, CZ has been
looking for ways to cut costs. Reducing reimbursements for
medicines is believed to be one of the options. "We can save much
money when physicians prescribe more rationally," according to a
spokesperson. To achieve this, CZ wants to assist physicians as
much as possible. For example, there will be a 'coach', a
psychologist, to advice on how individual prescribing behavior can
be adjusted. Prescriptions will be analyzed and compared on a
monthly basis.
Interestingly, participating physicians say they strongly doubt
whether the experiment will actually result in changing their
prescribing behavior. "I guess it is going to be very difficult', says
de Wit. "For nine years we have provided continuing education to
teach more rational prescribing to family physicians. But it hasn't
made a damn difference. Prescribing behavior rarely depends on
cognitive factors. It is mostly determined by established habits, and
it is very difficult to change those. I think a financial stimulus will
work better."
De Wit tells about how once he analyzed prescribing behavior of
himself and some of his colleagues in collaboration with a
pharmacist. "It became clear that doctors absolutely don't realize
how often they prescribe given drugs. They thought they prescribed
a certain drug only sporadically, but the huge amounts of
prescriptions of those drugs by them was telling quite a different
story. As evaluator of their own prescribing behavior they are not
reliable". Something similar was concluded from a recent survey by
the Dutch Medical Association amongst 696 members, both family
physicians and specialists. Although the vast majority (81 percent)
stated to allow only moderate influence of pharmaceutical
companies in their prescribing, over half of them said they did not
see any problem in buying shares of those companies, despite the
business interest that is established that way. Carrying out regular
research for pharmaceutical companies was not seen as a problem
by 37% of them.
"Health Insurers Holland", the umbrella organization of all 55 health
insurers in Holland, expects many insurers to follow the example of
CZ. "All members are currently busy with these kind of issues',
says spokesperson W. Annard. Health insurer ZAO from Amsterdam
wants to run an identical project as the one in Heerlen. Annard: "If
all family physicians in Holland would prescribe drugs more
appropriately, based on accepted standards of the Dutch
Association of Family Physicians, we could save tens of millions of
guilders".
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