Two countries that were affected by the recent economic recession in different ways, and amended their pharmaceutical policies very differently, have provided researchers with an invaluable data set pointing to the strengths and weaknesses of contrasting pharmaceutical sector policies. The use of antipsychotic medicines across Finland and Portugal following the recession has been analysed in order to gauge the impact of pharmaceutical policy interventions.

Christine Leopold of Gesundheit Österreich, Vienna, Austria, and colleagues looked at monthly sales data for antipsychotic medicines in Portugal and Finland between January 2007 and December 2011 [1]. They estimated changes in overall use and generics market share by comparing pre-policy and post-policy levels and trends. Markedly different alterations to pharmaceutical policy in Finland and Portugal led to increases in generics market shares of major antipsychotic products, but also a slight decrease in the use of antipsychotic medicines overall.

Different European countries have developed different strategies to contain medicines expenditure during tough economic times. Despite these differences, they all aim to cut costs without limiting access to much needed medicines. Antipsychotic medicines are essential for the treatment of severe chronic mental illnesses such as schizophrenia, bipolar disorder and autistic disorders. Leopold et al. studied these relatively expensive medicines because they represent a large component of public spending on medicines, and are frequently a target of cost-containment policies [2, 3].

Although the pharmaceutical sector policies in both Finland and Portugal gave rise to an increased market share for generics, the slight decrease in overall use of antipsychotic medicines was a concern since these drugs might have been needed more, rather than less, during an economic recession.

Finland and Portugal altered their policies in very different ways. Finland introduced a well-prepared mandatory generics substitution policy in April 2003, requiring pharmacists to substitute higher priced branded medicines with less-costly generic versions. Portugal’s approach was less uniform, comprising a mix of cost-containment measures including statutory discounts granted to public payers, changes in reimbursement rates, and a generics campaign that were ongoing before and after October 2010.

The most frequently sold active substance in both countries (clozapine in Finland and risperidone in Portugal) did not increase in generics market share, but this was for very different reasons. Risperidone already had a 90% share of the market in Portugal, so this was unlikely to increase significantly. In Finland, meanwhile, clinicians might have been reluctant to switch patients from clozapine to generic drug alternatives due to reports of worsening clinical status associated with generics substitution [4].

Nevertheless, two of the three leading active substances in the antipsychotic class (quetiapine and risperidone) experienced substantial increases in generics market share in Finland. While in Portugal, the combination of policies resulted in a major increase in generics market share for one molecule, amisulpride.

Several different strategies to contain medicines expenditures have been in place across Europe [5, 6]. Changes in patient co-payments for medicines and increases in value-added taxes on medicines were among the most frequently implemented cost-containment measures in 2010 [7]. These measures tend to shift cost burden to those who need medicines. While pharmaceutical sector cost-containment policies might achieve financial savings for the public health system, it is possible that they also have unintended effects in the form of decreased use of needed medicines when patients cannot afford to pay a higher share of medicines costs.

Initiatives aimed at increasing generics uptake play an important role in reducing pharmaceutical expenditure by using lower-priced medicines, where available, instead of expensive originator medicines. Key policies to encourage generics use have been devised for different stakeholders: prescribers, pharmacists and patients. At the beginning of 2013, 22 out of the 27 European Union Member States had generics substitution in place, and 23 allowed International Nonproprietary Name (INN) prescribing [8]. Lithuania and Slovakia, recently chose to switch from voluntary to obligatory INN prescribing because previous voluntary policies had not been fully enforced and tended to be less successful in achieving planned outcome than mandatory policies [9]. Conversely, high generics uptake has been achieved in the UK with voluntary INN prescribing, and a decision was made against the introduction of generics substitution planned for 2010 following a public consultation.

The findings in this latest study highlight the importance of examining the long-term effects of policy measures. The authors conclude that: ‘Increases in cost-sharing may have beneficial short-term impacts on public spending, but might also entail unintended long-term reductions in utilization, particularly for economically disadvantaged populations.’

Competing interests: None.

Provenance and governance: Article abstracted based on published scientific or research papers recommended by members of the Editorial Board, internally peer reviewed.

Bea Perks, PhD, GaBI Journal Editor

References
1. Leopold C, Zhang F, Mantel-Teeuwisse AK, et al. Impact of pharmaceutical policy interventions on utilization of antipsychotic medicines in Finland and Portugal in times of economic recession: interrupted time series analyses. Int J Equity Health. 2014;13:53.
2. GaBI Online – Generics and Biosimilars Initiative. Changes in risperidone use in Austria after introduction of generics [www.gabionline.net]. Mol, Belgium: Pro Pharma Communications International; [cited 2014 Sep 16]. Available from: www.gabionline.net/Generics/Research/Changes-in-risperidone-use-in-Austria-after-introduction-of-generics
3. GaBI Online – Generics and Biosimilars Initiative. Implications of the changes in venlafaxine utilization in Sweden following generics [www.gabionline.net]. Mol, Belgium: Pro Pharma Communications International; [cited 2014 Sep 16]. Available from: www.gabionline.net/Generics/Research/Implications-of-the-changes-in-venlafaxine-utilization-in-Sweden-following-generics
4. Kluznik JC, Walbek NH, Farnsworth MG, Melstrom K. Clinical effects of a randomized switch of patients from clozaril to generic clozapine. J Clin Psychiatry. 2001;62 Suppl 5:14-7.
5. European Commission. European Economy. Carone G, Schwierz C, Xavier A. Cost-containment policies in public pharmaceutical spending in the EU. Economic Papers 461. 2012 [homepage on the Internet]. 2012 Sep 27 [cited 2014 Sep 16]. Available from: http://ec.europa.eu/economy_finance/publications/economic_paper/2012/pdf/ecp_461_en.pdf
6. GaBI Online – Generics and Biosimilars Initiative. French Government pushing generics [www.gabionline.net]. Mol, Belgium: Pro Pharma Communications International; [cited 2014 Sep 16]. Available from: www.gabionline.net/Generics/General/French-Government-pushing-generics
7. GaBI Online – Generics and Biosimilars Initiative. Generics policies in Europe have room for improvement [www.gabionline.net]. Mol, Belgium: Pro Pharma Communications International; [cited 2014 Sep 16]. Available from: www.gabionline.net/Generics/Research/Generics-policies-in-Europe-have-room-for-improvement
8. Vogler S, Zimmermann N, Habl C. Understanding the components of pharmaceutical expenditure—overview of pharmaceutical policies influencing expenditure across European countries. Generics and Biosimilars Initiative Journal (GaBI Journal). 2013;2(4):178-87. doi:10.5639/gabij.2013.0204.051
9. WHO Collaborating Centre for Pharmaceutical Pricing and Reimbursement Policies. Pharmaceutical policy monitoring exercise with national competent authorities representated in the PPRI (Pharmaceutical Pricing and Reimbursement Information) network. Bi-annually, latest update: February 2013 (unpublished).

Disclosure of Conflict of Interest Statement is available upon request.

Copyright © 2015 Pro Pharma Communications International

Permission granted to reproduce for personal and non-commercial use only. All other reproduction, copy or reprinting of all or part of any ‘Content’ found on this website is strictly prohibited without the prior consent of the publisher. Contact the publisher to obtain permission before redistributing.