Restricting access to costly drugs is not the answer to budget over-runs. David Labanyireports
The Health Service Executive (HSE) has been quick to identify demand-led drug schemes as one of the main causes of a €222 million cost over-run this year which has resulted in a freeze on health service recruitment.
Demand-led drug schemes subsidise medicines for patients who cannot afford the cost. The problem, according to the HSE, is that the cost of these schemes is increasing every year.
For 2007, the cumulative shortfall in the schemes is estimated at €168 million with a total cost of €826 million. The HSE has responded by establishing review groups to examine the "unsustainable" over-spending.
The extent of the over-runs are detailed in an internal HSE study from June which found that annual increases in the number of people using the schemes, rather than rising medicine costs, were responsible for over-runs.
The HSE report provides an indication of the soaring cost of treating two of the State's biggest public health challenges: the epidemics of obesity and diabetes.
Noting the rapid rise in prescriptions for cholesterol-reducing drugs, the HSE study says: "Lifestyle choices can contribute to the growth of these drugs since it is easier to reduce cholesterol by taking medication than by changing habits."
Prof Gerald Tomkin, a consultant physician at the Blackrock and Beacon Clinics in Dublin and president of the Diabetes Federation of Ireland, says the Republic is in the grip of an explosion in obesity and diabetes cases.
He says doctors are switching patients to newer insulin-related products much sooner as these products enable better regulation of a patient's blood sugar levels.
The HSE report noted that this practice was adding significantly to medicine costs. In the three years to 2006, prescriptions for one of these products, Insulin Aspart, rose by more than 230 per cent.
Tomkin says it would be a mistake to respond to cost over-runs by restricting access to newer drugs.
"People with budgets tend to only look one or two years ahead. What is often forgotten is it is far more cost-effective to treat these patients with the most effective drugs on the market and keep them out of the hospital system.
"If someone gets a stroke, becomes blind or has an amputation that is hugely expensive for the community. About half of all patients in coronary care units have diabetes or pre-diabetes."
But what of the HSE's claim that prescribing cholesterol-reducing drugs is easier than persuading the patient to change their lifestyle?
Tomkin replies that in the same way as an alcoholic can struggle with drink, the overweight can struggle with food. "We do advise overweight patients. We do send them to dietitians. But sometimes this isn't enough. We need better ways to change lifestyle."
He adds that diabetes and obesity have seen a series of new drug products coming onto the market in recent years.
Last year the HSE spent €21.5 million buying Atorvastin, one of the more commonly prescribed and expensive cholesterol-reducing drugs. Prescriptions for this drug doubled last year.
The High Tech Drugs (HTD) scheme pays for medicines prescribed in hospitals to counter donor tissue rejection for transplant patients and HIV/Aids or drugs in chemotherapy. Last year 30,000 people accessed this scheme and the number of patients grew 60 per cent in the three years to 2006.
Some medicines covered by this scheme are among the most expensive available. A one-month supply of the drug Tracleer, used to treat respiratory illness, costs €2,986.
However, the drugs used to treat arthritis accounted for the largest expenditure under this scheme with €23 million spent on this area in 2005, according to the HSE.
John Church, chief executive of Arthritis Ireland, says one reason why the cost of arthritis drugs is rising is the growing use of biologic drugs. These seek to suppress the parts of the immune system that might trigger joint damage and inflammation.
"We now have 10-year trial data and doctors are becoming more confident prescribing them for people with rheumatoid arthritism," Church said. "Yes, they are expensive. But on the positive side these drugs are helping people to go back to work and result in less dependency on their GP and the hospital system," he says.
Despite rheumatoid arthritis affecting about 1 per cent of the population, or an estimated 40,000 people, this area has also seen several new drug launches in the past 18 months.
The HSE has also identified a sharp rise in prescriptions for adult anti-depressants, which grew by 50 per cent in the three years to 2004.
Drogheda-based GP Dr Harry Barry does not believe that this indicates a change in the rate of depression. Instead, he thinks a greater proportion of sufferers are now being identified.
"At any one time about 7 per cent of the population would be at risk of depression and I'd say that's held pretty steady."
Barry is a director of Aware and also the author of Flagging the Problem - A new approach to Mental Health. He says because Ireland lacks the resources for a holistic approach to treating depression, medication is often the only option.
"Most people will only require medication for six to eight months but the absence of CBT [cognitive behavioural therapy] services mean they are more likely to relapse. Depression should be treated holistically and we need back-up services to reduce the relapse rate," Barry says.
Ireland's ageing population is another factor contributing to rising prescriptions, according to Stephen McMahon of the Irish Patients Association. "More people in their late 40s and early 50s are having their cholesterol checked, maybe as a result of the amount of cholesterol-reducing foodstuffs being advertised on television at the moment."
Defending the right of patients to the best care available, McMahon says he does not want to see "a situation where Irish patients are going to court to secure access to vital medicines".
"It should also be pointed out that there are enormous mark-ups on medicines throughout the schemes," McMahon says.
Pharmacists dispensing medicines under the Drug Payment Scheme earn a 50 per cent mark-up on the ingredient cost of the medicine, on top of a dispensing fee.
In a statement released in response to questions from this newspaper, the HSE says it is reviewing the demand-led schemes and in particular "the impact of high-cost drugs". It says its objective is to provide "rational, cost-effective prescribing".
The HSE also says a recently negotiated agreement with the Irish Pharmaceutical Healthcare Association will see "a containment of costs in the community drug schemes".
According to the HSE, the new agreement with pharmacists will see a 35 per cent reduction in the cost of patent-expired drugs.
The management of some demand-led schemes has caused concern for the Comptroller and Auditor General. In a 2005 report, John Purcell found €23 million of medicines were purchased but not dispensed between the years 2000 and 2003.