E-DRUG: Use of generic or brand names in prescriptions (2)
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John
Experience in the USA and other countries is that a more comprehensive approach is needed looking at the whole medicine use system, controlling or 'power' factors, (dis)incentives and enforcability. Generic policies include mandatory generic prescribing, prescriber (dis)incentives to prescribe generics, flat or regressive dispensing margins and generic substitution plus the regulatory environment is important - drug quality, price competition, registration incentives, labeling, promotion. Some examples and thoughts related to this below.
1. As you intimate, even if they do not prescribe by generic name, how can it be enforced? Even so, there is no guarantee that a prescription written in generic name will result in generic dispensing - the pharmacist may still dispense the brand product. Legal provisions and incentives for pharmacists to dispense generics need to be explored. If they receive a percentage mark-up, they will tend to sell more expensive items. If they just receive a flat dispensing fee, that incentive is removed. A certain level of pharmaceutical training is presumed so as to recognise when substitution may not be in the patient's interest i.e. non-bioequivalent formulations.
2. Ideally the law should allow generic dispensing to take the 'power' away from the prescriber - unless the doctor states on the prescription that he does not want generic substitution, it should be allowed (even required) that a generic (the cheapest available) be dispensed. Some countries require patient consent to this, others just that they need to be informed. Note: the legal wording needs to be careful - past experience has had drug companies producing prescription pads with the words 'Do not substitute' (or similar) to hand out for doctors to use; in other cases there was just a tick box for doctors to indicate they did not want generic substutition which is too easy (and could be produced ready-checked) - ideally (from the point of view of promoting use of generics) they should be made to write it out.
3. Power can also be given to the patient in the law - that they can request a generic at the time of dispensing if the doctor has not indicated that one should not be dispensed. Of course, the public knowledge and perception of generics may need to be addressed here. An approved generic list can be made available if there are also low quality generics on the market. Price transparency is also important for patients to see what they have to gain.
4. In health insurance, (dis)incentives and formularies can be built in to promote use of generics.
5. Regulation to ensure availability and price competition among generic products is important. The Hatch-Waxman Act of the USA is an example of how legislation may be required to promote getting generic medicines onto the market (if they are not there and not competitively priced, it's no good having generic prescribing and substitution regulations). Regulation of drug promotion is also needed to some degree.
I will send you some more info and file attachments by private e-mail.
Regards
Douglas Ball
Pharmaceutical consultant
douglasball[AT]yahoo.co.uk
Douglas Ball <douglasball@yahoo.co.uk>