Picture it: you’re feeling under the weather and you traipse over to the doctor, assuming you’re lucky enough to get an appointment quickly, and she says you need to take something, and what pharmacy will you pick it up in?
You then head off down to the pharmacist, queue for a bit, then tell them you have a prescription waiting. There’s a bit of banter about the weather, and you take great interest in the shelves of vitamin pills and hot water bottles as you wait for your medicines to be prepared.
Finally, they arrive nicely bagged and presented with a smile by the shop assistant. That will be €30, she says, brightly.
You’re a bit taken aback. That sounds dear. Do you:
1. Just accept it and pay up quickly; you do want to get better soon, after all;
2. Query the amount and look for a discount; or
3. Ask for the script the pharmacy has printed off, and head for another pharmacy, while the assistant un-bags the medicines.
It doesn’t take a genius to work out that most of us will go for the first option, either out of embarrassment or a lack of time. The moment is pure transaction asymmetry. As a consumer, you have put in too much effort, gone too far in the process of buying the medicines and probably feel too unwell to contemplate any further delay in getting them.
The consequences of this situation, as it is played out daily by all of us across the nation’s 2,000 pharmacies, were laid bare last week in a study revealing massive differences in the prices we pay for essential prescription drugs.
The most expensive pharmacies are charging almost double the price imposed by the cheapest pharmacies, the researchers from Trinity College Dublin and Royal College of Surgeons in Ireland (RCSI) found.
Aspirin, for example, cost €9.12 in the highest-charging 10 per cent of pharmacies, but just €4.62 in the cheapest 10 per cent.
The cost of prescription paracetamol varied from €5.12 to €9.93, and that of the steroid drug prednisolone from €6 to €11.25.
With each of us spending an average of €44 a month on pharmaceuticals, these variations in price really matter. While there are State schemes to provide free or subsidised medicines, up to 60 per cent of the population cannot avail of them, and so have to fund their own drug costs. For example, you can spend up to €80 a month on medicines without qualifying for a subsidy under the drug payment scheme.
Price variations in essential medicines are not unique to Ireland. One US study found the maximum price of prescribed eardrops was 20 times more than the minimum.
But the study highlighted a separate issue around transparency. Up to 15 per cent of the 1,500 pharmacies surveyed declined to provide a price for a medicine by phone or email. Hardly any provide them online – outlets such as Freynes Pharmacy in Clondalkin, whose website lists the prices of 20 common drugs, are very much the exception.
In some US states, pharmacies are required to display most prescribed drug prices on websites created for this purpose.
Ireland differs from other countries in that chains are more expensive than independent pharmacies. One US study found chains were cheaper but the Irish researchers found they were charging more for nine of the 12 medicines included in their study.
Paul Kenny runs two Haven pharmacies in Tramore, Co Waterford. With more than 7,000 lines of product in his stores, across different drug strengths and quantities, he says it simply isn’t practical to list the price of all of them.
“I am committed to transparency on prices. If a patient comes to me with an expensive prescription, the first thing I’ll say to them is: ‘Did the doctor not warn you this will be dear?’
“In my experience, people pick their pharmacist for their expertise and professionalism, because they have a relationship with them or, conversely, because they are seeking anonymity. Price comes way down the order of importance compared to these considerations.
“But if someone is price sensitive, I would always encourage them to ask about the cost of something. I will always provide the price before prescribing, if I am asked.”
Kenny estimates the Health Service Executive, through various drug scheme, is the ultimate purchaser of about 80 per cent of the medicines he sells. Its prices are set, and have not changed “for years”. Pharmacists’ margins are getting “tighter and tighter” while their business costs are “spiralling”.
Ultimately, in many outlets, private customers end up subsidising the provision of medicines to HSE-funded patients to a greater or lesser extent.
E-prescribing, which was introduced as an emergency measure early in the pandemic, has been rightly lauded, but it has had the unintended effect of locking patients into the pharmacy they nominate to the GP when their medicines were being prescribed.
“The system is brilliant, but not fit for purpose,” says Kenny. “It’s a ‘push’ system, where the doctor asks you where you want to go for your medicine. What we need is a ‘pull’ system based on a unique health identifier that allows patients to present themselves wherever they wish to collect their medicines.”
This is not the first time the cost of prescription drugs has come under the microscope. In 2013, the National Consumer Agency surveyed prices charged by pharmacies for 42 common medicines, and found huge price differences between different outlets. However, it later emerged the agency had got some of the prices wrong, forcing it into an embarrassing climbdown.
The survey published this week, which covers over 1,500 medicines, is detailed and comprehensive. Unlike the previous NCA survey, researchers did not show their hand by declaring their academic goals.
The authors suggest several remedies for the phenomenon of wide price variations, starting with a “greater push for transparency” by the regulator, the Pharmaceutical Society of Ireland (PSI). They also suggest putting in place fixed prices for medicines, and variable dispensing fees based on volumes, a bit similar to the deal the HSE has with pharmacists. In Denmark, they point out, prices are the same across all pharmacies due to state regulation.
But by effectively ending the cross-subsidisation of public patients by private patients, this approach could result in some pharmacies going out of business.
Haggling over price is of little value. Just one in 20 pharmacies were willing to reduce their prices, the study found, in the form of reduced dispensing fees, price-matching or discretionary discounts.
The Irish Pharmacy Union says pharmacies are independent businesses and therefore obliged to set prices independently. In this context, price variations “are to be expected” as in any other sector.
The price of prescription medicines dropped 16 per cent between 2016 and 2021, it points out.
“Pharmacists also regularly advise patients regarding the availability of lower-cost medications such as generic medications in order to save patients money,” a spokesman pointed out.
The PSI does not concern itself with pricing issues, except to advise members to be transparent.
“Anyone is entitled to know the price of their prescription medicine before it is dispensed,” according to a spokeswoman. “It is reasonable to ask the pharmacist about the price of medicines, and check prices across a few pharmacies, if this is feasible.”
The State’s consumer watchdog, the Competition and Consumer Protection Commission, told The Irish Times it had received 27 “contacts” from consumers relating to pharmacies, five of which concerned pricing issues. A spokeswoman said the commission would consider the findings of this study “and whether engagement with the sector is necessary in order to ensure that consumers are able to obtain prices before they purchase a prescription drug”.