How can Mary Harney reduce the drugs bill by €64 million? Dr Muiris Houston, Medical Correspondent, looks at her options
THE FURORE surrounding medical cards for the over-70s and the budgetary U-turn that followed mean there is huge pressure to achieve drug savings in the medical card scheme. The drive is on to implement a plan by January 1st to save €64 million from the national drugs bill.
What will this mean for patients? Will it affect doctors' jealously guarded right to use the best possible treatment for a particular patient? And could this be the beginning of drug rationing?
Many of the dilemmas facing the group, chaired by Dr Michael Barry, consultant clinical pharmacologist at St James's Hospital and director of the National Centre for Pharmacoeconomics (NCPE), which has been asked to report to the Minister for Health by December 1st, will be discussed from a cost-effectiveness perspective.
Pharmacoeconomics is the branch of health economics that focuses on the costs and benefits of drug therapy. It offers a framework to assess the relative cost-effectiveness of different treatment options. As the cost of healthcare balloons and financial resources to meet new expectations shrink, difficult choices have to be made.
Fortunately, Dr Barry and his colleagues at the NCPE are experts in the field. They have carried out a number of health technology assessments (the name given to value-for-money investigations of a drug or a medical device) - the NCPE with the Health Information and Quality Authority (Hiqa) advised Mary Harney that a national cervical cancer vaccine programme would be cost-effective.
An intuitively obvious place to begin looking for drug savings is in the area of generic prescribing. New drugs start life protected by a patent and can be manufactured only by the pharmaceutical company holding that patent. However, after some years, this exclusive licence runs out so that other manufacturers can enter the market with a cheaper version of the same drug. Some companies specialise in the production of branded generic drugs.
Dr Barry believes generic prescribing usually enhances cost-effectiveness but warns that this is not always the case in the Republic. "This is a consequence of the current pricing structure where there is very little difference between the price of the proprietary drug and the available generics. In fact, in some cases, the generic products are more expensive than the original branded product. In my view, the role of generic prescribing in producing significant cost savings is limited unless the price of generic products is reduced substantially."
Dr Barry encourages generic prescribing from a medication safety perspective, but he does not believe generic prescribing will produce large savings.
When GPs prescribe generically, it is legally open to the pharmacist to dispense any brand of the drug, not necessarily the cheapest available. So any generic initiative by the review group will have to address this issue also.
The Irish Medical Organisation (IMO) declined to comment on drug-savings issues in line with its policy since the over-70s medical card issue first arose. However, it is expected to be represented by the expert group. The group is likely to look at moving a number of drugs from prescription only to over-the-counter availability. This has been done in the UK with low-dose statins (cholesterol-lowering drugs) and the morning-after pill.
Here, there may be pressure to make nicotine replacement therapy (patches and other devices) available over the counter, although this risks attracting the ire of the powerful anti-tobacco lobby. Drugs designed to reduce stomach acid make up a considerable percentage of medical card drug costs and may be targeted.
There is a precedent here: the first generation acid suppressants (Tagamet and Zantac) can now be bought over the counter. Patients who take the latest generation of acid suppressants - proton pump inhibitors including Zoton and Protium - on a long-term basis may find they will be directed to a low dose over-the-counter version, which they will have to pay for themselves.
An area ripe for change is the use of nutritional supplements. They are the second most expensive item within the medical card scheme; costing the State €37.5 million last year. In addition, nutritional supplements accounted for more than €4.5 million under the drugs payment scheme and €3.5 million under the long-term illness scheme.
Anecdotal reports suggest some of these supplements are prescribed and used inappropriately. Devised for patients with cancer or those who have difficulty swallowing after a stroke, some doctors are concerned that the supplements are over-prescribed to drug addicts and others who simply sell them on.
A report from the National Medicines Information Centre concluded "there is a lack of good quality clinical data evaluating the use of oral nutritional supplements" in the community and that "the evidence base for their usage is poor".
Commenting on the cost-effectiveness of nutritional supplements, Dr Barry told The Irish Times, "one may reasonably query the €45 million per year expenditure on clinical nutritional supplements as a significant proportion is for oral nutritional supplements where the clinical evidence base is poor".
Another area suitable for reform is antibiotic prescribing. Research in the current issue of the Irish Medical Journal found antibiotic usage among medical card patients had risen by 25 per cent in 2000-2005. Within the figures were some alarming trends, including a doubling in the prescription of the quinolone group of antibiotics, the use of which has been linked to the development of MRSA and Clostridium difficile.
Reducing antibiotic prescribing would not just save money; it would help achieve the aims of the Strategy for Antimicrobial Resistance in Ireland (SARI).
Co-payments, whereby the medical card holder would pay a top-up fee to the pharmacist, have been shown to reduce medicine consumption. However, people may be less likely to cash in prescriptions for preventive drugs in this situation, so health outcomes may suffer. Drug formularies also have a mixed record. Essentially a limited prescribing menu, the formulary advises doctors to use just one or two drugs for every disease.
Ultimately, it will be up to the Minister for Health to decide on specific drug eligibility changes. With the ill-thought out ramifications of medical card proposals still reverberating around her ears, she and her advisers will need to exercise careful judgment in deciding where and on whom the axe will fall.
Strategies to reduce the bill
• Encourage generic prescribing and ensure pharmacy dispenses cheapest generic.
• Introduce a National Drug Formulary.
• Withdraw reimbursement for drugs with questionable efficacy.
• Introduce drug co-payments for medical card patients.
• Shift some drugs from prescription only to over- the-counter (OTC) availability.