Prescribing, prescription costs and adherence to formulary committee recommendations: long-term differences between physicians in public and private care

BACKGROUND

In southern Sweden, many general practitioners (GPs) participate in an extensive postgraduate drug education programme, and many health centres are also fed back crude local drug statistics from pharmacists in the area. Private physicians and hospital physicians have not participated in these programmes.

OBJECTIVE

The drug prescribing habits and costs of GPs, hospital physicians and private physicians were compared.

METHODS

Each March, from 1990 to 1997, all prescriptions dispensed at the eight pharmacies in Växjö, a city and municipality in southern Sweden, were registered, specifying drug(s) prescribed, price, patient's age, sex and area of residence, and prescriber's place of work and category.

RESULTS

Overall, the costs of prescribed drugs increased with time, even in 1997 when the prescribing volume was reduced due to changes in the reimbursement system. The cost increase was caused by increased prescribing of newer, more expensive drug alternatives. However, within each of the eleven major drug groups, the drugs prescribed by GPs were less expensive than those prescribed by hospital physicians and, particularly, private physicians. Moreover, even though GPs prescribed more and a wider range of drugs, they also had a higher degree of adherence to the recommendations by the formulary committee.

CONCLUSION

GPs prescribed less expensive drugs and had a higher degree of adherence to the recommendations by the formulary committee than other categories of physicians. One reason for these differences may be that the GPs participated in regional and local educational activities aimed at the rationalisation of drug prescribing.

The use of emergency contraception in Australasian emergency departments

OBJECTIVE

To review the prescribing of emergency contraception by emergency departments in Australasia and compare it with other providers.

METHODS

A postal questionnaire was sent to the director of each of the 79 Australasian College for Emergency Medicine accredited emergency departments in Australasia inquiring about the availability and prescribing habits for emergency contraception within each department.

RESULTS

Of the 79 emergency departments, 69 (87.3%) responded to the questionnaire and were aware of the 'emergency contraception regimen'. The majority of departments prescribed appropriately (56%) and only one department did not arrange adequate follow up. Anti-emetics are always used by 45 departments (78.9%). Discussion of future contraceptive needs at the time of presentation was only undertaken by 25 departments (43.9%). Written clinical guidelines for emergency contraception were present in 28 departments (40.6%).

CONCLUSIONS

Emergency departments are accessed by patients requesting contraception following unprotected intercourse or contraceptive failure. The prescribing of emergency contraception in Australasian emergency departments is comparable with other providers but substantial improvements could be made. Suggestions to assist this improvement include written clinical guidelines and patient information and purpose-made medication packs.

Prescription drug prices: why do some pay more than others do?

The fact that sick elderly people without prescription drug coverage pay far more for drugs than do people with private health insurance has created a call for state and federal governments to take action. Antitrust cases have been launched, state price control legislation has been enacted, and proposals for expansion of Medicare have been offered in response to price and spending levels for prescription drugs. This paper offers an analysis aimed at understanding pricing patterns of brand-name prescription drugs. I focus on the basic economic forces that enable differential pricing of products to exist and show how features of the prescription drug market promote such phenomena. The analysis directs policy attention toward how purchasing practices can be changed to better represent groups that pay the most and are most disadvantaged.

Regional differences in the incidence of rheumatoid arthritis in Finland in 1995

OBJECTIVE

To investigate regional differences in the incidence of rheumatoid arthritis (RA).

METHODS

Those subjects entitled to receive drug reimbursement for chronic inflammatory joint diseases in 11/21 central hospital districts (population base about 1.8 million adults) in Finland during 1995 were studied. The incidence rates from these central hospital districts were compared.

RESULTS

A total of 1213 subjects were entitled to drug reimbursement for chronic inflammatory joint disease which had started at the age of 16 or over. Of these, 598 subjects satisfied the American Rheumatism Association 1987 criteria for RA. The age adjusted incidence of RA was 31.7/100 000 (95% CI 29.2 to 34.4) and varied significantly (p<0.001) among the central hospital districts, ranging from 16.3 to 44.8/100 000.

CONCLUSION

There are regional differences in the incidence of RA. The reasons for these are probably environmental rather than genetic.

Analysis confirms pharmacy driving health care cost hikes

Data insight: What drove last year's 6.6% increase in overall healthcare costs? Pharmacy cost increases. An analysis by the Center for Studying Health System Change also confirms that insurer premium increases are outstripping cost increases.

The cost of prescription medicines to patients

The study compares the cost-sharing (co-payment) arrangements for prescribed medicines in a sample of EU countries. Through a set of typical prescription scenarios, the cost burden to individual patients of prescriptions are examined, in the context of drug price, and from the perspective of therapeutic need. The cost to patients of medicines is consistently lower in some, and higher in other, countries, regardless of the type of prescription charge system. Fixed charge systems, as opposed to graduated co-payment systems, are obviously more likely to lead to similar charges for the treatment of comparable clinical conditions, but depending on the level of the charge, can result in the patient paying a higher charge than the price of the drug to the health organisation. Exemption from charges for prescription medicines, commonly relate to clinical condition and level of income. Some systems also have age-related criteria and apply ceilings to the total prescription cost burden borne by the patient. The impact on patient costs of specific policy formulations is discussed and a proposal is made for cost convergence for comparable therapies. The method used in this study may also provide a route for investigating model systems prior to implementation.

The effect of longevity on spending for acute and long-term care

BACKGROUND

The proportion of the population made up of elderly persons in the United States is projected to increase from 13 percent of the population in 2000 to 20 percent by 2030. The implications for health care expenditures may be profound, because elderly persons use health care services at a greater rate than younger persons. We estimated total expenditures for acute and long-term care from the age of 65 years until death and in the last two years of life.

METHODS

We combined data from Medicare, the National Mortality Followback Survey, and the National Medical Expenditure Survey to estimate total national expenditures for health care according to the age at death. We also simulated expenditures with the use of projected demographic characteristics of two cohorts: people turning 65 in 2000 and those turning 65 in 2015.

RESULTS

Total expenditures (in 1996 dollars) from the age of 65 years until death increase substantially with longevity, from $31,181 for persons who die at the age of 65 years to more than $200,000 for those who die at the age of 90, in part because of steep increases in nursing home expenditures for very old persons. Spending in the last two years of life also increases with longevity, but a reduction in Medicare expenditures ($37,000 for persons who die at the age of 75 years and $21,000 for those who die at the age of 95) moderates the effect of the increase in nursing home expenditures ($6,000 for those who die at the age of 75 years and $32,000 for those who die at the age of 95). Health care spending for women is consistently higher than that for men, after adjustment for the increased longevity of women. Simulations show that increased longevity after the age of 65 years has a relatively small effect on the anticipated increase in spending, especially for services covered by Medicare, from 2000 to 2015. The effects of the larger number of people born in 1950 than in 1935 and the larger number of people surviving to the age of 65 years are much more important.

CONCLUSIONS

In the United States, the effect of longevity on expenditures for acute care differs from its effect on expenditures for long-term care. Acute care expenditures, principally for hospital care and physicians' services, increase at a reduced rate as the age at death increases, whereas expenditures for long-term care increase at an accelerated rate. Increases in longevity after the age of 65 years may result in greater spending for long-term care, but the increase in the number of elderly persons has a more important effect on total spending.

The effect of new and continuing prescription drug use on cost: a longitudinal analysis of chronic and seasonal utilization

OBJECTIVE

To provide basic information about 2 factors contributing to rising prescription drug costs--utilization trends and product selection.

BACKGROUND

Prescription drug costs have risen sharply in recent years, and continued growth is expected. There is little consensus about appropriate cost-management strategies, in part because quantitative data on the causes and implications of increased drug costs are lacking.

METHODS

This study followed 463,820 continuously enrolled adult (> or = 18 years of age on January 1, 1996) utilizers of 15 chronic or seasonal therapeutic classes for 2.5 years (January 1996 through June 1998) using a pharmacy benefit manager's multiple-payer claims database. Outcome measures included (1) change in utilization rate, (2) relationship between new use and utilization growth, (3) stability of the treated population (ie, mostly long-term use vs high rates of turnover), and (4) product mix changes (ie, cost per dispensed day for 1996 vs 1997 and for new vs continuing users, controlling for inflation).

RESULTS

Of the 463,820 utilizers, 97% were commercially insured and 3% enrolled in Medicare risk plans; 40% were enrolled in managed care and the remainder covered by indemnity insurance. Rates of growth and turnover varied substantially by class. The highest 2-year utilization rate change was 66.7% for antihyperlipidemic agents; change was < 10% in only 3 classes. Across classes, an average of 38.7% of 1997 users were new (ie, no use in 1996) and an average of 34.0% of 1996 users were dropouts (ie, no use in 1997). Utilization growth depended heavily on treatment continuation; classes with high dropout rates (eg, antirheumatic, antiasthmatic) did not have high growth rates, even with high rates of new use. In most classes, costs were not higher for new than for continuing users. In some classes, however (eg, antipsychotic, antidiabetic), both new and continuing users increased their use of newer, more expensive products.

CONCLUSIONS

Because factors underlying rising prescription drug costs vary by therapeutic class, cost-containment strategies should address these differences. Further research is needed to assess the clinical and economic costs and benefits of rapid growth in the utilization of certain therapeutic classes.

Medical care expenditures for selected circulatory diseases: opportunities for reducing national health expenditures

OBJECTIVES

Circulatory system diseases are a significant burden in terms of morbidity, mortality, and use of health care services. This article presents total, per capita, and per condition US medical care expenditures in 1995 for circulatory diseases according to sex, age, and type of health service.

METHODS

Total personal health care expenditures estimated by the Health Care Financing Administration for each type of health care service are separated into components to estimate patient expenditures by age, sex, primary medical diagnosis, and health care service for all diseases of the circulatory system, heart disease, coronary heart disease, congestive heart failure, hypertensive disease, and cerebrovascular disease.

RESULTS

Expenditures for circulatory diseases totaled $127.8 billion in 1995 (17% of all personal health care expenditures), $486 per capita, and $1,636 per condition. Approximately one half of expenditures was for hospital care and 20% was for nursing home care. Heart disease accounted for 60% of circulatory expenditures. Expenditures increased with age and reached 35% of expenditures among persons aged 85 years and older, which was almost $7,000 per capita. These relationships vary somewhat according to the specific circulatory disease, type of health care, and age.

CONCLUSIONS

Expenditures increase with age and circulatory diseases can be expected to command an increasing share of national health expenditures as the number and proportion of the population that is elderly grows. The alteration of lifestyles and medical interventions provide many opportunities to prevent circulatory diseases and to reduce national health expenditures.

A cost analysis on the pattern of asthma prescribing in the UK

There is a need to establish the proportion of adult asthmatics at each step of the recommended asthma management guidelines, the cost of their prescribed treatment, and a revised cost of treatment assuming patients who were suboptimally controlled were moved up a step. Actual prescription and cost figures and a theoretical projection of an ideal scenario was calculated from a sample of general practices in Great Britain from the Doctors Independent Network. They comprised 102 nationally distributed practices and 17,206 adult patients with a diagnosis of, and prescription related to, asthma recorded between October 1993 and March 1994. Ninety-one per cent of patients received treatment within a recognized step of the guidelines. Of these, 80% were at steps 1 and 2. Employing excess inhaled beta-agonist use as a proxy for control of asthma, between 55% and 69% of patients at Steps 1-3 should receive treatment at a higher step. This could lead to an increased expenditure of up to Pound Sterling 4.66 per adult patient per month. This would imply a rise in the annual UK cost of antiasthma prescriptions for adults from Pound Sterling 388m to a possible Pound Sterling 533m. The United Kingdom Government audit commission has suggested that current expenditure on asthma treatment appears to be insufficient. Using an entirely different approach this study has confirmed that a significant increase in asthma prescribing costs is likely to be needed if optimal control of asthma is to be achieved.

Varying health care provider objectives and cost-shifting: the case of retail pharmacy in the US

In this paper we investigate the relationship between health care provider objectives, cost-shifting, and prices by exploring the relationship between state Medicaid pharmacy reimbursements and average prices paid by pharmacy retail customers for four distinct pharmaceutical products across the US in 1994. We develop a more general theory than past researchers to enable provider objectives to vary with Medicaid pharmacy reimbursement levels. We find that provider objectives and the direction of relationship between Medicaid pharmacy reimbursements and retail prices vary with Medicaid pharmacy reimbursement levels. At high Medicaid pharmacy reimbursement levels we find a consistent negative relationship across products. At low Medicaid pharmacy reimbursement levels, the direction of the relationship is product-specific. As a result, policy-makers should be aware that policies affecting reimbursements from government-sponsored health insurance will also affect retail customers that include the uninsured. Paradoxically, for certain products if a state cuts a generous Medicaid reimbursement level this could hurt uninsured patients, whereas cuts in a stingy Medicaid reimbursement rate may help uninsured patients.

The association of insurance type with costs of dispensed drugs

This study examines the association between types of prescription drug insurance coverage and the unit cost of dispensed drugs. Logistic regression and ordinary least squares regression were used to assess differences in the use of brand name and generic drugs and the unit cost of dispensed brand name or generic drugs across four insurance categories: Medicaid, private third party, indemnity, and uninsured. The results show that private third-party and indemnity prescriptions were more likely to be dispensed with brand name drugs. Also, indemnity patients and the uninsured were dispensed brand name and generic drugs with lower unit costs. The findings have ramifications for the design of prescription drug insurance benefits and suggest that physicians may respond to the economic situation of their patients when prescribing drugs.

Differences in prescription drug utilization and expenditures between Blacks and Whites in the Georgia Medicaid population

To address policy concerns regarding prescription drug access by vulnerable minority groups, we analyzed prescription drug use and spending among black and white enrollees in the Georgia Medicaid program. Using a two-part model estimating use and level of use of any prescription drugs, the study examined black/white differences controlling for age, sex, and Medicaid eligibility characteristics. Results showed black enrollees were significantly less likely to use any prescription drugs and received significantly fewer prescriptions than white enrollees. After adjustment, the black/white difference for children was 43%, with black children using 2.7 fewer prescriptions relative to white children. Patterns of use were similar for adults and the elderly, with black adults using 4.9 fewer prescriptions, and black elders using 6.3 fewer prescriptions, than their white peers. Spending rates per full-year enrollee were similar to utilization patterns and maintained the black/white differential. White Medicaid enrollees had higher use and spending than black enrollees across most high-volume therapeutic drug categories. The study explores several possible explanations for these differences.

[Prescriptions, access, and expenses on drugs among users of health services in Mexico]

OBJECTIVE

To analyze the medical prescription, drug access and drug expenditure by patients based on the National Health Survey in Mexico, 1994.

MATERIAL AND METHODS

A descriptive analysis of drug access and expenditure was undertaken and predictive factors for medical prescription were identified by logistic regression for 3,324 patients.

RESULTS

78% of the patients received drug prescriptions. 92% of the Social Security patients and 35% of the Ministry of Health patients received drugs free of charge (p = 0.000). The region with the highest poverty index received the least amount of drugs free of charge. Regarding drug expenditure of patients who purchased drugs, median expenditure was 40.00 pesos (12.50 USD). Private health service patients spent significantly more than public health service patients.

CONCLUSIONS

Drug access and drug expenditure are linked to socioeconomic factors and to the institutions attended by patients. The Mexican health system faces, among others, the challenge of increasing the equity of access to medical drugs.

The effect of increased prescription drug cost-sharing on medical care utilization and expenses of elderly health maintenance organization members

OBJECTIVES

The nature and extent of prescription drug benefits for the elderly are a continuing concern for health-care managers and policy makers. This study examined the impact of increased prescription drug cost-sharing on the drug and medical care utilization and expenses of the elderly.

METHODS

Two groups of well-insured Medicare risk-based members of a large health maintenance organization (HMO) had their copayments increased in different years during a 3-year period. Four 2-year analysis periods were established for comparing these elderly groups. During one analysis period, copayments did not change in either group.

RESULTS

Moderate increases of from $1 to $3, from $3 to $5 per copayment, and from 50% per dispensing to 70% per dispensing with a maximum payment per dispensing resulted in lower annual per capita prescription drug use and expenses. No consistent annual changes were observed in either medical care utilization (office visits, emergency room visits, home health-care visits, hospitalizations) or total medical care expenses across analysis periods.

CONCLUSIONS

No consistent relationships were observed between increased copayments per dispensing and medical care utilization and expense. Future research needs to address the impact on the classes of medications received and related health status, and the impact of larger increases in copayments per dispensing on medical care and health-related factors.

Prescription drug spending: the impact of age and chronic disease status

OBJECTIVES

The purpose of this study was to examine how pharmaceutical expenditures vary by age and the presence of chronic health problems.

METHODS

Data from the 1987 National Medical Expenditure Survey were used to obtain nationally representative estimates of outpatient prescription drug expenditures for the noninstitutionalized population and the fraction of total health expenditures used to purchase medications for age-chronic disease population subgroups.

RESULTS

Although the elderly make up 12% of the population, they account for 34% of total pharmaceutical expenditures. Pharmaceutical expenditures are 9% of total expenditures for children, 13% for nonelderly adults, and 23% for the elderly. Among nonelderly adults, approximately one third have at least one chronic condition and account for over two thirds of drug expenditures. Among the elderly, 36% have three or more chronic conditions and account for 57% of drug expenditures for this group; 41% of total drug expenditures are for cardiovascular or renal drugs.

CONCLUSIONS

Significant pharmaceutical spending is for treatment of chronic conditions, which subjects insurance coverage to adverse selection and could affect the design of prescription drug benefit packages. Current enrollees in Medicare risk management plans who have drug benefits may face significantly higher out-of-pocket expenses for pharmaceuticals if capitation rates are cut as a means of controlling Medicare program expenditures.

An analysis of predictors of prescription drug costs among Medicaid nursing home residents in Texas

A study was conducted to examine the relations among patient-specific demographic characteristics, previous prescription costs and utilization, and subsequent prescription costs for a population of 55,677 Medicaid nursing home residents in Texas. Patient-specific factors, based on previous patient utilization and cost levels, exist within the Texas Medicaid nursing home population that may serve as predictors of subsequent prescription costs. Although some statistically significant relations exist between prescription costs and patient demographic factors such as age, sex, and location, these demographic factors are of little or no practical value in prediction of prescription costs for subsequent periods of time.

[An analysis of the diagnoses and prescription for chronic patients at a health center]

OBJECTIVE

To find out if there are differences between inhabitants ages 14-64 with prescription charge (group A), pensioners ages 14-64 without prescription charge (group B), and pensioners aged over 64 without prescription charge (group C), related with chronic morbidity, associated treatment and costs data.

DESIGN

A crossover descriptive study (1995).

SETTING

Urban primary health care centre.

PATIENTS AND OTHER PARTICIPANTS

Participants are inhabitants 14 and over assigned to this health centre (12,605), included in a data bank register, patients are participants with at least a chronic diagnostic (7,007).

MEASUREMENTS AND MAIN RESULTS

Participants data were transferred to a practice computer system. Three groups (above) were established according to age band and prescription charge status: group A (73.6% participants), B (8.4%), and C (18%).

CONCLUSIONS

Inhabitants ages 14-64 without prescription charge were a differentiated group related with number of chronic diagnoses, number of items to chronic treatment prescribed, and annual average chronically drug costs. So they are intended for use in the future in allocation of budgets to primary health care centres.

[Pharmaceutical expenditure in primary care according to the prescription source]

OBJECTIVE

To find the origin of primary care pharmaceutical prescription and where expenditure is attributed.

DESIGN

A descriptive study of a prospective character.

SETTING

Medical clinics of a primary care team at the Torre del Mar Health Centre, Málaga.

MAIN RESULTS

A total of 2,580 prescriptions, whose average price was 1,415.4 pesetas, with a range from 135 to 35,889 pesetas, were issued. An average of 143.3 prescriptions a day were issued during the days analysed. The number of prescriptions issued by PC itself made up more than half the prescriptions, similar to the number of prescriptions originating elsewhere. The average price is greater for outside prescriptions than for prescriptions from within PC. Total accumulated cost was 3,651,912 pesetas. Expenditure on outside prescriptions was 1,774,783 pesetas, 48.59% of total cost. Total cost of prescriptions from within PC was 1,733,701 pesetas, 47.47% of the total.

CONCLUSIONS

PC has been assigned the role of issuing most prescriptions in the health-care system. This causes various problems within PHC: 1) a major administrative overload; 2) a great imaginative effort to try to avoid bureaucratic burdens; and 3) a real ability to rationalise the offer of medicines using quality criteria of only about 50%, as the other 50% of medicines originates outside PHC. We believe an extension of the programmes to guarantee quality in specialist care is needed, particularly of those programmes relating to pharmaceutical prescription.

A critical review of the remuneration systems for pharmacists

This paper provides a critical review of different systems of remunerations of pharmacists which exist in various countries: the percentage mark-up, the graduated mark-up, the capitation system, the fee for service system and mixed system. In these different systems, we refer to the various ways the provisions of pharmaceutical services are paid and reimbursed rather than how persons who physically deliver the services are paid. Therefore, the differences among various types of remuneration may not impact directly the level of responsibility and motivations of the various employees or owners in contact with the patient. The dispensing service remains the essential service of the pharmacist in all systems. However, according to the types of remuneration, the revenue of the pharmacist can be more or less linked to the volume and the price of drugs. Capitation systems, professional allowance and fees in particular can be used to shift the objective of the pharmacist towards increased professionalism. In each system, policy makers, when they can negotiate with the whole national profession, can use the remuneration system to achieve public policy objectives such as cost containment, better drug use, or provisions of large packages of services. This paper discusses to what extent each system can contribute to such objectives. In order to achieve public policy objectives, it may be time to shift the valuation of pharmaceutical services towards more safe and effective therapy instead of safe and effective drugs.

Pharmaco-economic information and its effect on prescriptions

Reports on a small-scale study of 30 general practitioners and 30 specialists in Greece where pharmaco-economic information was presented to these prescribers and an attempt made to observe changes in reported choice of treatment consequent on this exposure. Concludes with a credible level of statistical significance, that information which also takes into account economic performance criteria is likely to influence the prescription decision of the practitioners. Suggests, from a commercial point of view, that this offers the opportunity to pharmaceutical companies to complement their offerings so that they can be better targeted to those prescribers most likely to be influenced by this information. Notes that, from a general societal point of view, the question needs to be raised about the extent to which the independence of the prescriber might be eroded through the presence or absence of such information and thus the best interests of the patient safeguarded.

The effect of an Rx-to-OTC switch on medication prescribing patterns and utilization of physician services: the case of vaginal antifungal products

OBJECTIVE

We examined the impact of over-the-counter (OTC) availability of vaginal antifungal products, beginning in January 1991, on medication prescribing patterns and utilization of physician services.

DATA SOURCES AND STUDY SETTING

Data on utilization of health care services and prescription medications by female members (ages 11 and older) of the Fallon Community Health Plan (FCHP), a group model health maintenance organization and a component of the Fallon Health Care System of central Massachusetts. The census for such individuals increased from 49,551 in January 1990 to 67,365 in December 1992.

DESIGN

Time-series analyses were employed to assess changes in prescribing patterns of vaginal antifungal products and physician visits for vaginitis from January 1, 1990 through December 31, 1992. Monthly numbers of prescriptions for vaginal antifungal products and physician visits per 100 members were measured. Monetary savings relating to the prescription-to-OTC switch were also estimated.

DATA COLLECTION METHODS

The computerized management information system of FCHP contains records on utilization of all health care services and prescriptions filled, collected as part of routine fiscal activities. We identified all vaginally administered products on the FCHP formulary used for the treatment of vaginal candidiasis and determined the number of prescriptions filled for these agents during each month of the study period. We also identified the number of physician office visits characterized by the ICD-9-CM code 616.10 ("vaginitis and vulvovaginitis, unspecified") occurring during each month of the study period.

PRINCIPAL FINDINGS

For the one-year period after OTC availability of vaginal antifungal products (January 1991 through December 1991), we estimated that the number of prescriptions dispensed for these products was reduced by 6.42 per 100 female FCHP members ages 11 and older. Physician visits for vaginitis were reduced by 0.66 per 100 members. Estimated savings to the Fallon Health Care System for the one-year period following OTC availability were $42,528 in medication costs and $12,768 to $25,729 for costs associated with physician visits, depending on use of laboratory testing in patient evaluations.

CONCLUSIONS

The findings of this study suggest that the prescription-to-OTC switch of vaginal antifungal treatments reduced health care costs to the insurer in the managed care setting. These favorable effects on costs for the insurer need to be weighed against shifts in medication costs to consumers and potential adverse consequences to the patient relating to errors in self-diagnosis.

Are prescribed and over-the-counter medicines economic substitutes? A study of the effects of health insurance on medicine choices by the elderly

This article examines the influence of insurance coverage on the selection of over-the-counter (OTC) and prescribed (Rx) medicines in treating less serious health problems. Because health insurance policies typically provide no coverage for OTC products, a low list price for an OTC may exceed the after-insurance expense associated with a much higher-priced prescription. Under these circumstances, rational individuals with insurance will choose prescribed medicines even if OTCs are equally effective. Ten common health problems typically managed with either Rx or OTC medicines were selected for analysis. The study population consists of elderly Pennsylvanians surveyed during 1990 who reported suffering one or more of these conditions (N = 2,962). Multivariate analysis confirmed that 1) people with prescription coverage are significantly more likely to medicate a given problem than are those without it; and 2) given the decision to medicate, the presence of insurance significantly increases the level of Rx use and significantly reduces the level of OTC use. As expected, the effect was strongest among people with the most complete prescription insurance coverage. The article discusses the implications of these findings in the context of national health reform and Food and Drug Administration policy regarding Rx-to-OTC switches.

Off the prescription pad and over the counter: the trend toward drug deregulation grows

In the future, regulatory agencies may authorize the switch of more drugs from prescription-only to over-the-counter status. This could have the double effect of reducing the number of doctor visits and cutting drug costs. Although some physicians worry about the escape of reasonably potent drugs from medical surveillance, pharmacists are assuming a more significant counselling and medication-tracking role. This article looks at the negative and positive sides of drug deregulation from the perspectives of the physician, pharmacist and patient.

The effect of a patient charge and a prescription regulation on the use of antihypertension drugs in Limburg, The Netherlands

On 1 February 1983 a patient charge was introduced for prescription drugs for persons insured under the Dutch Sickness Funds Insurance Act. The charge consisted of a co-payment of NLG 2.50 per prescription item up to a maximum of NLG 125 for each family per calendar year. In the period before the introduction of the charge a prescription regulation was in force. For the majority of drugs this rule directed that each prescription item should be for a dosage of not more than 30 days. The prescription regulation was officially introduced on 1 January 1981 and ceased with the introduction of the charge. The effect of both measures on the use of antihypertension drugs in Limburg was investigated in an interrupted time-series analysis. Both the prescription regulation and the charge appeared to have an effect on the number of prescription items per insurant and the number of units delivered per prescription item. However, neither measure resulted in a reduction in the number of units delivered per insurant or the number of 'defined daily doses' (DDDs) per insurant. These findings suggest that neither measure resulted in a decrease in the inappropriate or appropriate use of antihypertension drugs.

Who cares what it costs to dispense a Medicaid prescription?

Results of a 1992 Medicaid cost-of-dispensing study among North Carolina pharmacies are presented. The estimated statewide weighted average cost incurred by pharmacies to dispense a prescription was $5.37 in 1991. The variation in dispensing costs found among pharmacies of various sizes, organizational types, and locations is identified. Higher average dispensing costs were reported for large chain pharmacies and those pharmacies in urban areas. Considering the potential for expanded prescription drug benefits under a reformed health care system, the implications of the study's findings for pharmacy payment policy are discussed.

Effect of generic drug competition on the price of prescription drugs in Ontario

OBJECTIVE

To analyse the potential effect of generic drug competition on prices in Ontario to assess the costs and benefits associated with Bill C-22 (An Act to amend the Patent Act).

DESIGN

Comparison of the cost of the least and most expensive versions of all products sold by more than one manufacturer in 1991. The number of brand-name and generic drug companies marketing each of the products was recorded.

RESULTS

Of 1599 products 437 (27.3%) were made by more than one company. Almost half (44.6%) of the 437 were sold by two companies. The more companies that sold a drug the greater the difference in price between the least and most expensive versions. Similarly, as the proportion of generic drug companies in competition increased, the greater the price difference. When competition was between generic drug companies only, the price spread was smaller than when it was between brand-name drug companies only.

CONCLUSIONS

Generic drug competition can result in savings to the Ontario Drug Benefit Plan. A more in-depth analysis of the potential savings is necessary to fully assess the costs and benefits associated with Bill C-22.

Pricing pain: relief in sight on drug costs?

Rising prescription drug prices have given state and federal health policymakers a headache. With pressure from Capitol Hill, drug makers appear to be moderating their pricing.

Price indexes for pharmaceuticals used by the elderly

The analysis presented in this report was undertaken to identify those drug entities that account for a significant proportion of the retail expenditures for prescription drugs used by the elderly. Commercial data bases were used to develop fixed weight Laspeyres price indexes based specifically on drugs used in the elderly population. The indexes provide the capability to analyze price trends for drug groupings that are not possible with the producer price index (PPI) or the Consumer Price Index (CPI). From 1981 through 1988, the average annual rate of increase in manufacturers' prices was 9.1 percent, and retail prices increased at an average annual rate of 6.6 percent. The indexes represent potentially powerful tools in analyzing drug price trends, an important component of drug program expenditure forecasting and management.