A systematic review of the literature comparing the practices of dispensing and non-dispensing doctors

Financial incentives and prescribing behavior in primary care

Many healthcare systems prohibit primary care physicians from dispensing the drugs they prescribe due to concerns that this encourages excessive, ineffective or unnecessarily costly prescribing. Using data from the English National Health Service for 2011-2018, we estimate the impact of physician dispensing rights on prescribing behavior at the extensive margin (comparing practices that dispense and those that do not) and the intensive margin (comparing practices with different proportions of patients to whom they dispense). We control for practices selecting into dispensing based on observable (OLS, entropy balancing) and unobservable practice characteristics (2SLS). We find that physician dispensing increases drug costs per patient by 3.1%, due to more, and more expensive, drugs being prescribed. Reimbursement is partly based on a fixed fee per package dispensed and we find that dispensing practices prescribe smaller packages. As the proportion of the practice population for whom they can dispense increases, dispensing practices behave more like non-dispensing practices.

The Effect of Biosimilar Prescription Targets for Erythropoiesis-Stimulating Agents on the Prescribing Behavior of Physicians in Germany

OBJECTIVES

This study aimed to aid decision makers by analyzing the impact of introducing biosimilar prescription targets on physician prescribing behavior in the prescription of biologic erythropoiesis-stimulating agents in Germany.

METHODS

We combined secondary data of regional level biosimilar prescription targets and secondary data of routinely collected claims data of dispensed prescriptions by physicians operating within the statutory health insurance system in ambulatory care across 7 German regions from 2009 to 2015. Two-way fixed-effects regression analysis was used to identify the average treatment effect of introducing biosimilar prescription targets at the physician level. The main outcome of interest was the share of biosimilar prescriptions on all prescriptions within the substance group. We compared 6 regions that introduced biosimilar prescription targets with 1 region without any prescription target policy.

RESULTS

Introducing biosimilar prescription targets increased the average share of biosimilars between 6 percentage points (P < .05) in Hamburg and up to 20 percentage points (P < .001) in Saxony-Anhalt. Stratification of specialists by prescription volume and adoption status indicated heterogeneous effects. We identified similar but higher effects for high-volume prescribers. Disentangling of effects with regard to the composition of biosimilar share suggested that the increase in biosimilar share was driven by increased biosimilar use accompanied by a nonsignificant decrease in original biologics prescriptions.

CONCLUSIONS

Prescription targets to alter physician prescribing behavior meet their intended goals by increasing biosimilar share. Physicians partly responded to the policy by decreasing overall prescriptions of the target substance. Prescription targets might be a useful tool, but decision makers need to consider all aspects of potential responses.

Ten recommendations to improve pharmacy practice in low and middle-income countries (LMICs)

Medicines are important health interventions and their appropriate use could improve health outcomes. Throughout the globe, pharmacists play a very important role to improve the use of medicines. Though high-income countries are debating on futuristic approaches, independent prescribing of pharmacists, clinical skills, and to expand pharmacy services; a large majority of low and middle-income countries still lag behind to strengthen pharmacy practice. This paper presents a key set of recommendations that can improve pharmacy practice in low and middle-income countries (LMICs). The ten recommendations include (1) Mandatory presence of graduate-level pharmacists at community pharmacies (2) Clear demarcation of the roles and responsibilities of different categories of pharmacists (3) Effective categorization and implementation of medicines into (a) prescription medicines (b) pharmacists only medicines (c) over the counter medicines (4) Enforcement of laws and regulations for the sale of medicines (5) Prohibiting doctors from dispensing medicines (the dispensing separation between pharmacists and doctors). (6) Involving pharmacies and pharmacists in Universal Health Coverage Schemes to improve the affordability of medicines (7) Strengthening national medicines regulatory authorities to improve the quality, safety, and effectiveness of medicines (8) Training of pharmacists in clinical skills, vaccination, and minor ailment schemes (9) Promoting independent medicines information for consumers and healthcare professionals by developing national medicines information strategy (10) Mandatory Continuing Professional Development (CPD) programs for the Pharmacists.

Medication adherence and clinical outcomes in dispensing and non-dispensing practices: a cross-sectional analysis

BACKGROUND

Most patients obtain medications from pharmacies by prescription, but rural general practices can dispense medications. The clinical implications of this difference in drug delivery are unknown. This study hypothesised that dispensing status may be associated with better medication adherence. This could impact intermediate clinical outcomes dependent on medication adherence in, for example, hypertension or diabetes.

AIM

To investigate whether dispensing status is associated with differences in achievement of Quality and Outcomes Framework (QOF) indicators that rely on medication adherence.

DESIGN AND SETTING

Cross-sectional analysis of QOF data for 7392 general practices in England.

METHOD

QOF data from 1 April 2016 to 31 March 2017 linked to dispensing status for general practices with list sizes ≥1000 in England were analysed. QOF indicators were categorised according to whether their achievement depended on a record of prescribing only, medication adherence, or neither. Differences were estimated between dispensing and non-dispensing practices using mixed-effects logistic regression, adjusting for practice population age, sex, deprivation, list size, single-handed status, and rurality.

RESULTS

Data existed for 7392 practices; 1014 (13.7%) could dispense. Achievement was better in dispensing practices than in non-dispensing practices for seven of nine QOF indicators dependent on adherence, including blood pressure targets. Only one of ten indicators dependent on prescribing but not adherence displayed better achievement; indicators unrelated to prescribing showed a trend towards higher achievement by dispensing practices.

CONCLUSION

Dispensing practices may achieve better clinical outcomes than prescribing practices. Further work is required to explore underlying mechanisms for these observations and to directly study medication adherence rates.

Understanding and expectation towards pharmaceutical care among patients, caregivers and pharmacy service providers: a qualitative study

Background

Over the past decades, the pharmacist's role has changed from being 'compounders and dispensers' to one of 'medication therapy manager' providing pharmaceutical care (PC). The transformation of pharmacy practice and its benefits, however, seem to be poorly understood by patients and caregivers (consumers) even in advanced health systems.

Objective

This study aims to assess the comprehension of consumers in Singapore towards PC and expectations on the scope of pharmacy services today.

Methods

This qualitative study was conducted among 51 consumers and pharmacy staff (pharmacy providers) in a tertiary acute care hospital in Singapore through 45 semi-structured interviews. Participants were sampled from inpatient and outpatient settings. Data were transcribed, coded and analysed by thematic analysis.

Results

Thirteen pharmacy technicians, 14 pharmacists and 14 out of 24 patients and caregivers, agreed to be interviewed. Reasons such as minimal English and unsure of pharmacy services were cited for declining interviews. From the interviews, the majority of the consumers did not understand the differences in roles between pharmacists and doctors beyond the basics of doctors diagnosing and pharmacists dispensing. Eighteen (75%) consumers remain unaware that pharmacists are trained to provide additional services such as medication enquiry services and optimisation of drug therapy. In addition, consumer expectations have expanded beyond transactional encounters, with 15 (63%) consumers expecting personalised services. Five (19%) pharmacy providers also expect the use of automation to boost efficiency and improve patients' convenience. Seven (15%) of the participants hope to see better prediction with analytics and, therefore, pre-emptive management of medication errors.

Conclusions

There is an incomplete understanding regarding PC and the roles of pharmacy providers among healthcare consumers today. Beyond basic service provisions, expectations of pharmacy practice have become more experience-oriented. Policy changes that expand pharmacists' roles must be matched with corresponding publicity and education efforts to encourage service utilisation.

Scaling up effective treatment of hypertension-A pathfinder for universal health coverage

High blood pressure is the world's leading cause of death, but despite treatment for hypertension being safe, effective, and low cost, most people with hypertension worldwide do not have it controlled. This article summarizes lessons learned in the first 2 years of the Resolve to Save Lives (RTSL) hypertension management program, operated in coordination with the World Health Organization (WHO) and other partners. Better diagnosis, treatment, and continuity of care are all needed to improve control rates, and five necessary components have been recommended by RTSL, WHO and other partners as being essential for a successful hypertension control program. Several hurdles to hypertension control have been identified, with most related to limitations in the health care system rather than to patient behavior. Treatment according to standardized protocols should be started as soon as hypertension is diagnosed, and medical practices and health systems must closely monitor patient progress and system performance. Improvement in hypertension management and control, along with elimination of artificial trans fat and reduction of dietary sodium consumption, will improve many aspects of primary care, contribute to goals for universal health coverage, and could save 100 million lives worldwide over the next 30 years.

Financial incentives and physician prescription behavior: Evidence from dispensing regulations

In many health care markets, physicians can respond to changes in reimbursement schemes by changing the volume (volume response) and the composition of services provided (substitution response). We examine the relative importance of these two behavioral responses in the context of physician drug dispensing in Switzerland. We find that dispensing increases drug costs by 52% for general practitioners and 56% for specialists. This increase is mainly due to a volume increase. The substitution response is negative on average, but not significantly different from zero for large parts of the distribution. In addition, our results reveal substantial effect heterogeneity.

Sale of medicines by Registered Medical Practitioners at their clinics: Legal and ethical issues

In India, manufacturing, storing, transportation, distribution, and dispensing of drugs are licensed and regulated under the drugs and cosmetic act, 1940; Indian Medical Council Act, 1956; the Pharmacy Act, 1948; and the Narcotic Drugs and Psychotropic Substances Act, 1985. Prescribing and dispensing medicines at the same time to their patients by registered medical practitioners (RMPs) is a well-known practice in all systems of medicine across the country. Further, the kind of branded medicines a patient gets from the clinics will come wrapped in a huge profit margin for RMPs, and this has been an alternative source of income to them. Dispensing and selling of medicines by RMPs at their clinics to their patients may represent a significant potential conflict of interest with the medical ethical principles, namely autonomy, beneficence, and non-maleficence and it raises various ethical and legal challenges. This article focuses on the ethical and legal issues of this practice and emphasizes the need for a proactive and dynamic approach to meet the rising demand for quality healthcare in India.

Do doctors in dispensing practices with a financial conflict of interest prescribe more expensive drugs? A cross-sectional analysis of English primary care prescribing data

OBJECTIVES

Approximately one in eight practices in primary care in England are 'dispensing practices' with an in-house dispensary providing medication directly to patients. These practices can generate additional income by negotiating lower prices on higher cost drugs, while being reimbursed at a standard rate. They, therefore, have a potential financial conflict of interest around prescribing choices. We aimed to determine whether dispensing practices are more likely to prescribe high-cost options for four commonly prescribed classes of drug where there is no evidence of superiority for high-cost options.

DESIGN

A list was generated of drugs with high acquisition costs that were no more clinically effective than those with the lowest acquisition costs, for all four classes of drug examined. Data were obtained prescribing of statins, proton pump inhibitors (PPIs), angiotensin receptor blockers (ARBs) and ACE inhibitors (ACEis). Logistic regression was used to calculate ORs for prescribing high-cost options in dispensing practices, adjusting for Index of Multiple Deprivation score, practice list size and the number of doctors at each practice.

SETTING

English primary care.

PARTICIPANTS

All general practices in England.

MAIN OUTCOME MEASURES

Mean cost per dose was calculated separately for dispensing and non-dispensing practices. Dispensing practices can vary in the number of patients they dispense to; we, therefore, additionally compared practices with no dispensing patients, low, medium and high proportions of dispensing patients. Total cost savings were modelled by applying the mean cost per dose from non-dispensing practices to the number of doses prescribed in dispensing practices.

RESULTS

Dispensing practices were more likely to prescribe high-cost drugs across all classes: statins adjusted OR 1.51 (95% CI 1.49 to 1.53, p<0.0001), PPIs OR 1.11 (95% CI 1.09 to 1.13, p<0.0001), ACEi OR 2.58 (95% CI 2.46 to 2.70, p<0.0001), ARB OR 5.11 (95% CI 5.02 to 5.20, p<0.0001). Mean cost per dose in pence was higher in dispensing practices (statins 7.44 vs 6.27, PPIs 5.57 vs 5.46, ACEi 4.30 vs 4.24, ARB 11.09 vs 8.19). For all drug classes, the more dispensing patients a practice had, the more likely it was to issue a prescription for a high-cost option. Total cost savings in England available from all four classes are £628 875 per month or £7 546 502 per year.

CONCLUSIONS

Doctors in dispensing practices are more likely to prescribe higher cost drugs. This is the largest study ever conducted on dispensing practices, and the first contemporary research suggesting some UK doctors respond to a financial conflict of interest in treatment decisions. The reimbursement system for dispensing practices may generate unintended consequences. Robust routine audit of practices prescribing higher volumes of unnecessarily expensive drugs may help reduce costs.

Separation of prescription and treatment in health care markets: A laboratory experiment

Health care is a credence good, and its market is plagued by asymmetric information. In this paper, we use a laboratory experiment to test the performance of a potential remedy discussed in the applied literature, the separation of prescription and treatment activities. We observe a significant amount of overtreatment (and a smaller nonpredicted amount of undertreatment) in our baseline environment. Requiring a different than the treating physician to provide diagnosis and prescription for free is an effective way to reduce overtreatment in our laboratory setting. This effect, however, is partially offset by an increased frequency of undertreatment. Allowing prescription and treatment physicians to independently set prices for their services reduces efficiency due to coordination failures: In sum, prices are often higher than expected benefit of patients, who in turn do not attend to the physician. Also contrary to theory, bargaining power does not play a significant role for the distribution of profits between physicians.

Delivery arrangements for health systems in low-income countries: an overview of systematic reviews

BACKGROUND

Delivery arrangements include changes in who receives care and when, who provides care, the working conditions of those who provide care, coordination of care amongst different providers, where care is provided, the use of information and communication technology to deliver care, and quality and safety systems. How services are delivered can have impacts on the effectiveness, efficiency and equity of health systems. This broad overview of the findings of systematic reviews can help policymakers and other stakeholders identify strategies for addressing problems and improve the delivery of services.

OBJECTIVES

To provide an overview of the available evidence from up-to-date systematic reviews about the effects of delivery arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on delivery arrangements and informing refinements of the framework for delivery arrangements outlined in the review.

METHODS

We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of delivery arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty or employment) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the findings. Two overview authors independently screened reviews, extracted data, and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence), and assessments of the relevance of findings to low-income countries.

MAIN RESULTS

We identified 7272 systematic reviews and included 51 of them in this overview. We judged 6 of the 51 reviews to have important methodological limitations and the other 45 to have only minor limitations. We grouped delivery arrangements into eight categories. Some reviews provided more than one comparison and were in more than one category. Across these categories, the following intervention were effective; that is, they have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Who receives care and when: queuing strategies and antenatal care to groups of mothers. Who provides care: lay health workers for caring for people with hypertension, lay health workers to deliver care for mothers and children or infectious diseases, lay health workers to deliver community-based neonatal care packages, midlevel health professionals for abortion care, social support to pregnant women at risk, midwife-led care for childbearing women, non-specialist providers in mental health and neurology, and physician-nurse substitution. Coordination of care: hospital clinical pathways, case management for people living with HIV and AIDS, interactive communication between primary care doctors and specialists, hospital discharge planning, adding a service to an existing service and integrating delivery models, referral from primary to secondary care, physician-led versus nurse-led triage in emergency departments, and team midwifery. Where care is provided: high-volume institutions, home-based care (with or without multidisciplinary team) for people living with HIV and AIDS, home-based management of malaria, home care for children with acute physical conditions, community-based interventions for childhood diarrhoea and pneumonia, out-of-facility HIV and reproductive health services for youth, and decentralised HIV care. Information and communication technology: mobile phone messaging for patients with long-term illnesses, mobile phone messaging reminders for attendance at healthcare appointments, mobile phone messaging to promote adherence to antiretroviral therapy, women carrying their own case notes in pregnancy, interventions to improve childhood vaccination. Quality and safety systems: decision support with clinical information systems for people living with HIV/AIDS. Complex interventions (cutting across delivery categories and other health system arrangements): emergency obstetric referral interventions.

AUTHORS' CONCLUSIONS

A wide range of strategies have been evaluated for improving delivery arrangements in low-income countries, using sound systematic review methods in both Cochrane and non-Cochrane reviews. These reviews have assessed a range of outcomes. Most of the available evidence focuses on who provides care, where care is provided and coordination of care. For all the main categories of delivery arrangements, we identified gaps in primary research related to uncertainty about the applicability of the evidence to low-income countries, low- or very low-certainty evidence or a lack of studies.

A qualitative study exploring physicians' perceptions on the role of community pharmacists in Dubai

Objective:

The aim of this study is to explore the perceptions of physicians operating within the boundaries of Dubai on the role of community pharmacists.

Methods:

Semi-structured interviews were done with 12 physicians working within the boundaries of Dubai Health Authority. Interviews mainly focused on understanding the perceptions of physicians on the role of community pharmacists in addition to willingness to integrating pharmacists in patient care process.

Results:

Key findings show that all interviewees agree that community pharmacists are important healthcare professionals. However, 7 physicians restrict the role of pharmacists to dispensing medicines. Physicians in Dubai are willing to collaborate with pharmacists, but more than half of them (7) think that pharmacists might interfere with their jobs.

Conclusion:

The study concludes that all informants agree that collaboration between community pharmacists and physicians definitely enhances patients’ drug therapy outcomes.

Does Physician Dispensing Increase Drug Expenditures? Empirical Evidence from Switzerland

This paper analyzes whether the opportunity for physicians to dispense drugs increases healthcare expenditures. We study the case of Switzerland, where dispensing physicians face financial incentives to overprescribe and sell more expensive pharmaceuticals. Using comprehensive physician-level data, we exploit the regional variation in the dispensing regime to estimate causal effects. The empirical strategy consists of a doubly-robust estimation that combines inverse probability weighting with regression. Our main finding suggests that dispensing leads to higher drug costs on the order of 34% per patient.

Analysis of the influence of recent reforms in China: cardiovascular and cerebrovascular medicines as a case history to provide future direction

BACKGROUND

Pharmaceutical expenditure has grown by 16% per annum in China, enhanced by incentives for physicians and hospitals. Hospital pharmacies dispense 80% of medicines in China, accounting for 46% of total hospital expenditure. Principal measures to moderate drug expenditure growth include pricing initiatives as limited demand-side measures.

OBJECTIVE

Assess current utilization and expenditure including traditional Chinese medicines (TCMs) between 2006 and 2012.

METHODS

Uncontrolled retrospective study of medicines to treat cardiovascular and cerebrovascular diseases in one of the largest hospitals in southwest China.

RESULTS

Utilization increased 3.3-fold for cerebrovascular medicines, greatest for TCMs, with expenditure increasing 4.85-fold. Low prices for generics were seen, similar to Europe. However, there was variable utilization of generics at 29-31% of total product volumes in recent years. There continued to be irrationality in prescribing with high use of TCMs, and the utilization of different medicines dropping significantly once they achieved low prices.

CONCLUSION

Prices still have an appreciable impact on utilization in China. Potential measures similar to those implemented among western European countries could improve prescribing rationality and conserve resources.

Dispensing doctor practices and community pharmacies: exploring the quality of pharmaceutical services

AIMS

This research sought (a) to investigate the similarities and differences in how pharmaceutical services are provided by community pharmacies (CPs) and dispensing doctor practices (DPs) and (b) to identify the issues relevant to determining the quality of pharmaceutical services in these settings.

BACKGROUND

UK pharmaceutical services, including dispensing prescriptions and public health advice, can be provided from both (CP) and, in rural areas, (DP). While there is much similarity between CPs and DPs in the types of services provided, there is also the potential for variation in service quality across settings.

METHODS

A postal questionnaire of DPs and CPs in South West England was conducted to provide a descriptive overview of pharmaceutical services across the settings. A subsection of questionnaire respondent sites were selected to take part in case studies, which involved documentary analyses, observation and staff interviews.

FINDINGS

Survey response was 39% for CPs (52/134) and 48% (31/64) for DPs. There were three CP and four DP case study sites, with 17 staff interviews. More pharmacies than practices were open at the weekend and they had more staff trained above NVQ level 2. Both doctors and pharmacists saw themselves as medicines experts, as being accessible and having good relationships with patients. Workplace practices and organisational ethos varied both within and across settings, with good practice observed in both. Overall, CPs and DPs have much in common. Workplace culture and an evidence-based approach to checking prescriptions and error reporting need to be considered in future assessments of service quality.

Do Professional Practices among Malaysian Private Healthcare Providers Differ? A Comparative Study using Simulated Patients

BACKGROUND

Malaysia, a South East Asian country, legally permits general medical practitioners in private clinics to dispense medicines. This possibly can dilute the pharmacist role in the provision of healthcare and pharmaceutical care and deprive patients to benefit from these services.

OBJECTIVE

This study explored, assessed and compared the current status of medicines labeling, patient's counseling, and symptomatic diagnosis by general practitioners and community pharmacists.

MATERIAL AND METHODS

This study used trained Simulated Patients (SP), who participated in a scenario of common cold symptoms at private clinics and community pharmacies. SPs explored medication labeling, patients counseling and symptomatic diagnosis undertaken by general practitioners and community pharmacists. Later, study authors assessed and compared these practices. The study was conducted during June 2011 in Penang, Malaysia.

RESULTS

The study used descriptive statistics and Fisher-exact test to analyze data. Regarding patients counseling standard, among 100 visits by simulated patients, 64 (64%) from community pharmacists provided information about the medicine name, its indication, dosage and route of administration versus 17 (42.5%) general practitioners during 40 visits (p=0.024). Concerning adherence to labeling standard, for instance, only in one pharmacy visit, (1%) the pharmacist wrote the name of the patient on the medication label versus in 32 (80%) of doctors' visits, the doctors adhered to this labeling standard (p<0.001). In all doctors' visits (n=40, 100%), SPs were asked about symptoms, whereas in 87 (87%) CPs' visits, pharmacists fulfilled this counseling standard (p=0.02).

CONCLUSION

Although pharmacists showed less compliance to medicine labeling and symptomatic diagnosis compared to doctors, their counseling of patients was better. Separation will definitely contribute to more concentration of each provider on his/her roles and improve and direct the experiences and skills towards being more patient oriented.

A price and use comparison of generic versus originator cardiovascular medicines: a hospital study in Chongqing, China

BACKGROUND

Developed countries use generic competition to contain pharmaceutical expenditure. China, as a developing and transitional country, has not yet deemed an increase in the use of generic products as important; otherwise, much effort has been made to decrease the drug prices. This paper aims to explore dynamically the price and use comparison of generic and originator drugs in China, and estimate the potential savings of patients from switching originator drugs to generics.

METHODS

A typical hospital in Chongqing, China, was selected to examine the price and use comparisons of 12 cardiovascular drugs from 2006 to 2011.

RESULTS

The market share of the 12 generic medicines studied in this paper was 34.37% for volume and 31.33% for value in the second half of 2011. The price ratio of generic to originator drugs was between 0.34 and 0.98, and the volume price index of originators to generics was 1.63. The potential savings of patients from switching originator drugs to generics is 65%.

CONCLUSION

The market share of the generics was lowering and the weighted mean price kept increasing in face of the strict price control. Under the background of hospitals both prescribing and dispensing medicines, China's comprehensive healthcare policy makers should take measures from supply and demand sides to promote the consumption of generic medicines.

Policies to promote use of generic medicines in low and middle income countries: a review of published literature, 2000-2010

OBJECTIVE

Review the literature on the impact of policies designed to enhance uptake of generic medicines in low and middle income countries (LMICs).

METHODS

We searched for publications related to generic medicines policies (January 2000-March 2010) and did a bibliometric, descriptive analysis of the dataset in addition to an analysis of studies evaluating the impact of pro-generic policies. We repeated a subset of this larger search in January 2012.

RESULTS

Of the 4994 articles screened, 315 (6.3%) full-text publications were related to generic medicines policies. Of these 315, 236 (75%) dealt with generic medicine policies in high-income countries, and 79 (25%) with policies in LMICs. In total, we found only 10 evaluation studies looking at the impact of competition, trade, pricing and prescribing policies on generic medicine price and/or volume. Key barriers to implementing generic medicine policies in LMICs are negative perceptions of stakeholders (e.g., generics are of lower quality) plus perverse private sector financial incentives to sell products with the highest profit margin. Other relevant barriers are legal/regulatory, such as the absence of generic substitution regulations. There also exists a general difficulty in promoting generics due to a lack of transparency in the pharmaceutical supply and distribution system, for example, a lack of price information provided by health care provider organizations to physicians.

CONCLUSION

There is little policy evaluation to determine which pro-generic policies increase generic medicines utilization in LMICs. Ensuring a functioning medicines regulation authority, creating a reasonably robust market of generic medicines and aligning incentives for physicians, consumers and drug sellers are necessary prerequisites for increasing the uptake and use of generic medicines.

Supply sensitive services in Swiss ambulatory care: an analysis of basic health insurance records for 2003-2007

Background

Swiss ambulatory care is characterized by independent, and primarily practice-based, physicians, receiving fee for service reimbursement. This study analyses supply sensitive services using ambulatory care claims data from mandatory health insurance. A first research question was aimed at the hypothesis that physicians with large patient lists decrease their intensity of services and bill less per patient to health insurance, and vice versa: physicians with smaller patient lists compensate for the lack of patients with additional visits and services. A second research question relates to the fact that several cantons are allowing physicians to directly dispense drugs to patients ('self-dispensation') whereas other cantons restrict such direct sales to emergencies only. This second question was based on the assumption that patterns of rescheduling patients for consultations may differ across channels of dispensing prescription drugs and therefore the hypothesis of different consultation costs in this context was investigated.

Methods

Complete claims data paid for by mandatory health insurance of all Swiss physicians in own practices were analyzed for the years 2003-2007. Medical specialties were pooled into six main provider types in ambulatory care: primary care, pediatrics, gynecology & obstetrics, psychiatrists, invasive and non-invasive specialists. For each provider type, regression models at the physician level were used to analyze the relationship between the number of patients treated and the total sum of treatment cost reimbursed by mandatory health insurance.

Results

The results show non-proportional relationships between patient numbers and total sum of treatment cost for all provider types involved implying that treatment costs per patient increase with higher practice size. The related additional costs to the health system are substantial. Regions with self-dispensation had lowest treatment cost for primary care, gynecology, pediatrics and for psychiatrists whereas "prescription only" areas had lowest cost for specialists with non-invasive and invasive activities.

Conclusions

The results indicate that payment methods for services and for prescription drugs are associated with variations in treatment cost that are unlikely warranted by different medical needs of patients alone. Promoting physician accountability of care by linking reimbursements to quality, not quantity, of services are important policy measures to be considered for health care in Switzerland.