Submitted: 10 June 2013; Revised: 11 June 2013; Accepted: 12 June 2013; Published online first: 20 June 2013
Vogler and Zimmermann have provided us with important insights regarding the activities of regional sickness funds in Austria to enhance rational prescribing. They show how the various sickness funds used a variety of different approaches to improve rational prescribing. This included physician training, monthly newsletters on changes in the reimbursement list and generics, information events, personal visits to physicians to discuss their prescribing habits, letters, analysis of prescriptions and feedback/benchmarking, software systems and financial incentives to encourage the prescribing of generics . They also targeted patients to enhance their acceptance of generics . This is important given concerns among some patients regarding generics and the potential implications for compliance if they are dispensed different branded generics on each occasion and any name confusion is not adequately addressed. Both issues need to be addressed to enhance generic utilization. [2–4]. The authors also document the recent involvement of sickness fund personnel in Hospital Drug and Therapeutics Committees (DTCs) to improve prescribing across the interface of hospital and ambulatory care [1, 5].
These activities are in addition to the existing activities by the Federation of Austrian Social Insurance Institutions to enhance prescribing efficiency. These include a ‘generics price link policy’ to lower the prices of both generics and originators [1, 6]. The various measures resulted in, for instance, a 72–77% reduction in prices of generic simvastatin and omeprazole respectively versus pre-patent loss originator prices in 2007 (expenditure/defined daily dose) . They also include prescribing restrictions to limit the prescribing of patented products in a class where all products are seen as similar in all or nearly all patients, e.g. statins and angiotensin receptor blockers (ARBs) versus angiotensin converting enzyme inhibitors (ACEIs), and more recently patented ARBs versus losartan [1, 6–10]. In addition, the Medicine and Reason Initiative involving all key stakeholders to produce approximately one guideline and patient information leaflet per year [1, 6]. One guideline per year was considered the maximum number that general practitioners can cope with. This combined with multiple stakeholder involvement enhanced their acceptance . This compares with guideline overload in France among ambulatory care physicians where 243 guidelines had been issued by 1999, leading to their limited use in practice and subsequent demise .
The authors point out in the introduction that the increasing use of generics versus originators and patented products in a class can save considerable resources without compromising care . This is especially important as more standard drugs lose their patents. For instance, it is estimated that between 2011 and 2016, products with current global sales of US$255 billion per year are likely to lose their patents [3, 4]. This is in addition to high volume products that have already lost their patents in the past decade including various proton pump inhibitors (PPIs), statins, selective serotonin re-uptake inhibitors (SSRIs) and ACEIs .
The authors also provide good reasons for selecting regional sickness funds, and conducting in-depth interviews . This approach subsequently provided a substantial insight and gives good guidance on potential initiatives that other European countries could consider, especially those with a mixture of national and regional activities to enhance rational prescribing, e.g. Italy, Spain, Sweden and UK [3, 4, 9, 11–13]. Guidance from Austria includes instigating sophisticated IT systems to monitor physician prescribing patterns and feeding these back to them as well as building trust between the ‘payers’ and physicians . The latter is seen as especially important to enhance physician acceptance of any payer activities, as seen for instance by the considerable acceptance by physicians of an essential medicine list (EML)—the ‘Wise List’—in Stockholm County Council in Sweden. Acceptance of the EML is enhanced enhanced by trust in those producing the guidance [1, 14]. Trust is also enhanced in Austria by the sickness funds providing independent evidence-based information, saving physicians time and resources . The accuracy of the findings documented in the paper, and their subsequent implications, is enhanced by the authors asking participating sickness fund members to review and approve the draft paper. This adds to the strength of the paper.
A key activity highlighted by the authors is the new role for the sickness funds in hospital DTCs, including training sessions for junior doctors and nursing staff . Improved interface management between hospital and ambulatory care is seen as increasingly important across countries to enhance the rational use of medicines. This especially since many new premium priced drugs are initiated in hospitals and these are often provided at low or no cost [1, 5]. The authors document a successful project in the province of Burgenland to enhance the prescribing of generics as well as improving understanding generally between hospitals and sickness funds as a result of these new initiatives . The authors subsequently documented increased cooperation between sickness funds and hospitals in recent years since these initiatives were first introduced , endorsing the rationale behind their introduction. This is to be welcomed. Such activities provide guidance to other countries, and mirror activities in Scotland, Spain and Sweden to improve this interface .
The authors also highlight the potential role for pharmacists to improve the rational use of medicines including generics . This builds on their role with distributing guidelines from the Medicine and Reason Initiative . Pharmacists have been increasingly used in other countries to help address possible name confusion and concerns regarding generics, especially if different branded generics are dispensed on each occasion [2–4, 12]. This may be a potential avenue for the sickness funds to explore in the future as there is currently no INN (International Nonproprietary Name) prescribing or generics substitution in Austria , and such activities have enhanced the use of generics and lowered their prices in other European countries [1, 3, 4, 11, 12, 15].
Finally, as pointed out, it would be useful for the authors to undertake research into the influence of the different multiple measures instigated by the different sickness funds on subsequent physician prescribing patterns. This could also include an analysis of the influence of the different communication strategies. We do know that multiple measures are typically needed to change physician prescribing habits [3, 4, 13, 16], and that different strategies are needed for different physician types to enhance the rational use of medicines [1, 17]. However, it would be useful both for key stakeholders in Austria, as well as other European countries, if it were possible to provide further insights into the potential influence of the different measure, or combined measure, on subsequent prescribing patterns.
Competing interests: None.
Provenance and peer review: Commissioned; internally peer reviewed.
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Author: Brian Godman, BSc, PhD, Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital Huddinge, SE-14186, Stockholm, Sweden; Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK; Liverpool Health Economics Centre, University of Liverpool, Liverpool, UK
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How do regional sickness funds encourage more rational use of medicines, including the increase of generic uptake? A case study from Austria