A HSE scheme to promote cost-effective prescribing may not have delivered value for money. Martin Wallreports.
For more than a decade, the State provided millions of euro in financial incentives to general practitioners in the medical card scheme to encourage them to adopt more cost-effective prescribing patterns in a bid to control soaring drug costs.
However, a new report by the National Centre for Pharmoeconomics has found that the incentive scheme, which was suspended by the Health Service Executive (HSE) over a year ago, was not working and could also in some cases have been hindering the objective of cost-effective prescribing.
The report found that GPs who were making savings under the incentive scheme were also prescribing fewer cardiovascular, respiratory or alimentary tract and metabolism medicines - including products which were safe and cost effective - and that while this could have reduced costs, it may not have represented value for money in overall terms.
The report says that one of the principal mechanisms for doctors to make savings on their drugs bill was by means of a greater use of non-branded or generic products.
However, it states that generic prescribing rates are falling even among those GPs who had been making savings under the incentive scheme.
The report also suggests that the recent agreement between the HSE and pharmaceutical manufacturers, which will see the price of off-patent medicines fall by 35 per cent, may generate more savings than than those anticipated with strategies such as generic substitution.
The introduction of the controversial indicative drug target saving scheme for GPs in 1993 represented one of the main attempts by the Government to place controls on the soaring cost of drugs in the community schemes.
At that stage the year-on-year rise in State expenditure on drug costs was running at around 10 per cent and the initial indications were that the scheme helped to slow this rapid rate of increase. However, total spending on the community drug schemes still increased from €170 million in 1991 to €1.366 billion in 2005.
Under the deal for the incentive scheme, reached between the Department of Health and the Irish Medical Organisation (IMO) in 1993, each GP was allocated an individual target for spending on drugs for patients.
Initially under the scheme, doctors could keep 50 per cent of the savings generated for investment in specific practice developments, with the balance going to the then local health board for investment in general practice overall, although the rules were amended over the years.
Although from the start there was strong criticism from some quarters about the ethics of the scheme, the funds generated were massive.
GPs received around €115 million, with the health board getting €18.5 million to facilitate improvements in general practice. Money generated under the scheme was used to develop new or improved practice premises, for the purchase of clinical equipment, for investment in computerisation or to expand services through new dedicated clinics and for research, education and training.
However, over time both the number of doctors making savings and the amounts involved dwindled. By 2005, there were only 53 GPs who made savings compared with 460 in 2000.
Eventually the scheme was suspended by the HSE, pending a review by the National Centre for Pharmoeconomics. Aspects of the scheme were also criticised by the Comptroller and Auditor General in a value-for-money report last year.
The report of the National Centre for Pharmoeconomics, which was completed last month, found that GPs who underspent on their targets (known as category C doctors) issued fewer prescription items per patients than those considered to be modest overspenders (known as category B doctors) or large over-spenders (known as category A doctors).
For 2005, category C doctors issued 25.7 prescription items per patient compared to 30.53 and 33.29 for category B and A doctors respectively.
"The cost per patient for all drugs prescribed for category C doctors was €527.17 in 2005 as compared with €646.21 and €740.03 for category B and A," the report states.
The report found that the category C doctors issued fewer prescriptions for cardiovascular drugs and that this trend appeared to be increasing over recent years.
It says that lipid lowering statin medications accounted for more than 10 per cent of total GMS expenditure on drugs (ingredient cost) in 2005.
It maintains that doctors in the B and C categories prescribed fewer lipid lowering agents - predominantly statins - compared to category A doctors.
"A recent study by Bennett et al (2006) investigated the reduction in cardiovascular mortality in Ireland over the past 20 years and attributed this reduction, in part, to the prescribing of lipid lowering medications," the report says. "Statin therapy has been shown to be safe and effective when used for the primary or secondary prevention of cardiovascular disease.
"Furthermore, this therapy has been demonstrated to be cost effective in the Irish healthcare setting for both primary and secondary prevention. The lower prescribing rates for lipid-lowering drugs for category B and C doctors may not be cost effective despite the lower ingredient costs in these groups," it adds.
"Therefore, the incentive to prescribe few medications including lipid-lowering drugs under the indicative drug target saving scheme may actually be hindering the objective of cost-effective prescribing," the report states.
The report also says that expenditure on alimentary tract and metabolism drugs accounted for more than 15 per cent of spending in the medical card scheme in 2005 and that similar prescribing trends were observed in this area with category C doctors issuing fewer prescription items per patient.
The report says that more than half of all expenditure in this area went on drugs known as proton pump inhibitors (PPI).
"It is apparent that category C doctors prescribe fewer proton pump inhibitors which may, in part, be due to the incentive offered under the indicative drug target saving scheme," it says. "The PPI group of drugs have been shown to be safe, effective and cost effective.
"Although it is difficult to be sure from the analysis of prescribing data, in the absence of diagnosis, the PPI prescribing by category C doctors outlined above may not represent value for money despite reducing costs," it states.
The report also maintains that similar prescribing trends were seen in relation to respiratory drugs.
The report says that one of the principal mechanisms for the incentive scheme to promote cost-effective prescribing was through enhanced use of generic medicines. However, recent data shows that generic prescribing rates are low and falling even further. It says that even among the category C doctors, who were generating savings, the percentage of generic prescribing in terms of items fell from 1998 to 2005.
The report says that the recent deal between the representative body for pharmaceutical manufacturers (IPHA) and the HSE, which will see the wholesale price of off-patent medicines reduce by around 35 per cent, "has significant implications for generic prescribing".
It says that the savings from this agreement "may exceed those anticipated with strategies such as generic substitution.
"When we consider the trends in the volume and expenditure associated with generic prescribing and the impact of the new IPHA/HSE agreement, the future role of the indicative drug target savings scheme in containing pharmaceutical expenditure must be questioned," it stated.
HSE chief executive Prof Brendan Drumm told the Dáil Public Accounts Committee earlier this month that the report's findings, which suggested that the scheme was "no longer achieving its stated objective to promote rational cost-effective prescribing by the GPs", were being considered by health service management to see how the scheme's original aims could now be best achieved.