A Study for the Establishment of Separation of Prescription and Dispensing
- Publication Date
- Series No.
A Study for the Establishment of Separation of Prescription and Dispensing
1. The background and objectives of the study
Since its implementation in August 2000, the separation of prescription and dispensing (hereafter 'the separation policy'or the policy' revealed as many problems as had been anticipated. These problems should be seen as 'teething pains'to endure in an inchoate stage, during which the policy is rated not so much by its potential positive effects-improvement of people's health through prevention of drug misuse and abuse, enhancement of professionalism by role division between doctors and pharmacists, and reduction in national medical expenditures-as by all the very real inconveniences it poses.
The aim of present study is to contribute to furthering the separation policy by focusing on assessing its performance and presenting strategies for improvement.
In order to assess the performance of the separation policy, this study analyzed the results of a number of researches conducted by a range of government and non-government organizations including the Korea Institute for Health and Social Affairs (KIHASA), the Health Insurance Review Agency (HIRA), and the Health Solidarity (HS). The study also analyzed various indicators pertaining to patients (medical service users), doctors and medical facilities (medical service providers), and pharmacies and pharmaceutical firms. Also, a total of four face-to-face and telephone surveys (twice for each) were conducted for the present study. The two surveys of each type were carried out six months apart on medical and pharmaceutical service users to grasp changes in the utilization of health care services and in their satisfaction and dissatisfaction therewith since the implementation of the separation policy.
3. Main findings
Results of the face-to-face surveys
Most of the interviewees pointed out the inconvenience of making a trip from medical institution to pharmacy and the complicated and time-consuming procedure from the point of prescription issuance to the point of having dispensed medication.
There have not been significant changes in the satisfaction rate with physician services. While there was a little increase in dissatisfaction regarding waiting time for physician services, the satisfaction rate with the overall medical service environment increased to some extent.
The satisfaction rate with the pharmacist's explanation of medication has increased slightly. As to the waiting time for getting medication, the percentage of those dissatisfied has increased slightly. Also, the proportion of those satisfied with the overall pharmaceutical service environment has increased.
There was a substantial increase in the percentage of those who thought they were better informed and explained. Most of the interviewees responded, however, that there was not much decrease in their use of drugs.
As to the overall assessment of the policy, some 80% responded 'inconvenient but bearable'
Results of the telephone surveys
Most of the interviewees pointed out the inconvenience of making a trip from medical institution to pharmacy and the complicated and time-consuming procedure from the point of prescription issuance to the point of having the medication dispensed.
Those who responded that the policy is 'inconvenient but bearable' accounted for 63.2% for the first survey and 64.5% for the second.
Although the results of these surveys can be seen as indicating that the separation policy is slowly gaining acceptance, there is an increasing need for developing effective strategies to minimize the waiting time for medical and pharmaceutical services and to improve the availability and variety of drug supplies at many local pharmacies.
HIRA's data on changes in prescription drugs before and after the separation policy and its assessment of the pharmaceutical reimbursement system show a continuous decrease in the use of antibiotics.
KIHASA's data on trends in the sales of misusable and abusable drugs reveals that the sales of both oral drugs and injection drugs is decreasing in terms of quantity but increasing to a degree in terms of value, which is likely to mean that high-priced drugs are increasingly replacing less expensive ones.
KIHASA's data on National Health Insurance (NHI) reimbursement claims shows that the proportion of antibiotic prescriptions in the total claim cases has decreased for all high frequency diseases since the separation policy.
HIRA's data indicates that the number of prescribed injection item per outpatient has continuously declined to reach 0.58 in May 2001, down 23.7% from 0.77 in May 2000. Also, the rate of injection prescription has declined from 60.82% in May 2000 to 45.94% in May 2001.
HIRA's data shows that there has been a steady increase in the drug cost per outpatient after the implementation of the separation policy. This is presumably because doctors are prescribing high-cost drugs more often than they used to before the implementation of the separation policy.
KIHASA's data on NHI reimbursement claims shows that the drug cost per day of prescribed medication has increased to an extent. The drug cost per prescription also has increased after the implementation of the policy. The rate of increase in drug cost per prescription was higher for chronic diseases (essential hypertension) than for acute respiratory diseases.
Also, the number of prescriptions of foreign-affiliated pharmaceutical products has increased at the fastest pace among all medicinal drugs registered under NHI. Meanwhile, while there has been an increase in the market share of original products, the market share of copy products containing the same active ingredients has decreased to some degree.
Since the implementation of separation policy, the market share of high-cost drugs has increased, while that of low-priced drugs has slightly decreased.
Number of days of prescribed medication
The number of days of prescribed medication per outpatient visit has continuously increased since the separation policy began.
Number of prescribed pharmaceutical items
KIHASA's data shows that there has been a decrease in the number of drug items per outpatient prescription since the separation policy began for both those with and without complications or comorbidities.
Implications drawn from the analysis of provider behaviors
That both the drug cost and the number of days of prescribed medication have increased unabated may be largely due to the recent expansion of NHI to cover patients having chronic disease. However, the continuous decrease in the number of drug items per prescription and in other quantity indicators suggests that there has taken place some improvement after the policy implementation.
4. Policy Suggestions
All parties concerned should make every possible effort to resolve social conflicts among interest groups, prevent squandering of stupendous social resources, and gather wisdom to focus on solving pending problems and improving the areas of weakness with a view to furthering the establishment of the separation policy.
The current restriction on the days of prescription medication should be abolished in order to ensure the convenience of patients with long-term medication needs. Also, prescription drugs must be fully demarcated from non-prescription drugs.
In order to promote social acceptance for generic prescriptions, more tests should be taken to demonstrate the pharmacological equivalence between brand name drugs and their low-cost alternative versions.
Medical and pharmaceutical associations and the government should reduce people's inconvenience by organizing and institutionalizing 'physician and pharmacist roster'for weekends and public holidays.
There should be severe sanctions on all collusive practices between doctors and physicians that distort the fundamental intent of the separation policy.
Social campaigns should be launched to encourage people to have a regular doctor and a regular pharmacist to increase their convenience.
Since what matters most in maximizing the effect of the separation policy is improving pharmaceutical services, appropriate pharmacist dispensing standards should be promptly established and education should be provided to render them effective.
Meanwhile, continuous monitoring efforts should be made to assess the performance of the separation policy and identify areas for improvement. In the case of pharmacies, in particular, the sales of prescription drugs have fallen while the sales of oriental herbal medicine and health foods have increased, requiring due measures to be taken based on prudent review of the current status.
To reduce the current prescription practices to a medically necessary and appropriate level would require multi-faceted mid to long-term approaches that involve establishing a prescription monitoring and feedback system, strengthening the compliance review pursuant to the prescription guidelines (clinical treatment guidelines), and providing education on proper prescription practices.
To curb the excessive use of high-cost drugs would require efforts to promote prescription of generic and other low-cost alternatives prior to adopting a full-scale reference pricing system. To encourage the use of low-cost alternatives, there is a policy option to allow consumers choose high-cost original products, but NHI should only reimburse the cost for their low-cost alternative counterparts when there is an alternative available, holding the consumer responsible for paying the rest.
The ultimate objective is more about revamping the current healthcare system in general than improving the separation policy in particular. To achieve such an aim requires establishing a long-term three-pillar medical security system that secures payments of small fees though family medical savings accounts (1st pillar), expenditures on fees for short-term hospitalization and high-cost outpatient services through social insurance premiums, and the financial means for major risk insurance, which requires high payments, through taxation (3rd pillar).
Another overriding issue is to foster trust among all groups in the healthcare sector and to forge consensus through public debates and opinions. In this regard, every issue concerning healthcare systems will be discussed by the 'Special Committee on Medical Reform'and the 'Special Committee for Pharmaceutical System Improvement and Healthcare Industry Development' both of which are to be operated under the Presidential Office.