Towards promoting rational drug use in SVG

by Tyrone Jack Tue, Nov 13, 2012

In the interest of the public health it is strongly felt that drugs cannot be viewed as ordinary commodities of commerce, as they are not like most other commodities. Drugs are not chosen directly by the buyer (the patient); the buyer is not always the responsible payer; and the buyer often has no background or the necessary information to evaluate or make a choice of a drug, which can at times have hazardous or even deadly consequences for the patient.{{more}}

Normal market economics have to be modified when applied to drugs, as assumptions are not easily fulfilled. This has been recognized in regard to pricing, demand and sale of drugs. Using special models, studies in the UK found that reducing the price of drugs did not markedly affect their use; uses were mainly dependent on the prescribing practices of the physicians. The public must therefore be protected from harm or potential harm caused by irrational prescribing habits. The state must, through public education, promote rational drug use. These argue well as a good economic and health policy.

Against this background, policy makers must find the best way to achieve the goal of protecting the public’s health through rational drug policies which promote rational prescribing. We must decide on the necessary regulation so to do. The Pharmacy Act # 375 of the 2009 revised edition of the laws of SVG. Sec.5: (b) places an obligation on the pharmacy Council to decide on matters related to the registration of Pharmacies amongst others and further in Sec. 5(h) it obligates the Council to make recommendation to the Minister on matters relating to the making of regulations; and (i) to make recommendation to the Minister with a view to achieve compliance with the requirements of the Act.

Thus far, the Council has reviewed the conditions under which pharmacies were allowed to practice in SVG prior to the Council’s existence (this it found was done merely upon acquisition of a trader’s license); the Council has designed a model application form for all new pharmacy applicants; they have produced a pharmacy construction guideline; gazetted the list of drugs that can be sold in shops or without the supervision of a pharmacist, list of pharmacies, pharmacists, pharmacist assistants and pharmacy owners and recommended through the Minister a body of regulation which it expected to provide the legal machinery required to achieve the administrative and technical goals of the Pharmacy, Act. This principally is to regulate the practice of Pharmacy inclusive of minimizing or eliminating conflict of interest issues. One way of advancing this is through the limitation on the percentage ownership shares of prescribers in pharmacies.

It is my view that where there is evidence that the physician’s ownership interest is sufficiently large, he can increase his dividends by increasing the pharmacy’s sales. The Council thought parliament ought to act to protect the public. Research across the globe has shown that doctors who also dispense drugs regularly, appear to prescribe more drugs than non-dispensing doctors, confirming the general recommendation that prescribing and dispensing should be separated whenever possible. To prevent this phenomenon, the practice in many jurisdictions is to require that prescribing practitioners divest their shares in pharmacy enterprise; failing to do so, the pharmacies are denied their annual licence.

I also hold the position that the state should disallow all forms of fee splitting between pharmacists and prescribing practitioners, if the Council has good reason to believe that fee splitting will occur and the patient’s free choice will be impinged.

The purpose of proposing a ban on fee-splitting in SVG is to protect and benefit the public and bring SVG in line with modern medical practice. It is presumed that a ban on direct fee-splitting protects and benefits the public because it insures that physicians will refer patients to pharmacies based on the patients’ needs, not on the physician’s desire for a referral fee. A physician who receives a percentage of all the payments which his patients make to a particular pharmacist may be inclined to refer his patients to that pharmacist, rather than to the pharmacy which is most convenient for the patient, or provides the best service, has the lowest prices, or employs the most highly regarded pharmacist. The economic incentive for the physician to recommend a particular pharmacy thus undermines the patient’s right to be properly advised and to select the most suitable pharmacy for his needs. The physician may also be tempted to prescribe particularly expensive or even unnecessary drugs in order to increase his referral fee from the pharmacist. In such a case, the patient’s right to reasonable and appropriate therapy is clearly jeopardized. Thus fee-splitting between pharmacies and physicians, in its most direct form, poses multiple possible harms to the public.

The potential harm to the public is no less, from less direct forms of fee-splitting. “A physician who receives a corporate dividend based either on the number of his patients who use a particular pharmacy or the total dollar amount spent by his patients at the pharmacy is just as likely to be influenced by the payment as a physician who is paid directly by the pharmacist. Likewise, a physician whose dividend is not tied to his referrals, but whose ownership interest is sufficiently large that he can increase his dividends by increasing the pharmacy’s sales, is likely to be influenced in the same way that he would be if the pharmacist paid him directly. In each of these situations, the payment to the physician does not come directly from the pharmacist, but the potential harm to the public is the same as if it did” [Attorney General, Richard Blumenthal October 2, 1992].

Support for my position comes from several research findings which can be provided to readers on request.

In SVG, the Council and the state should view that a problem exists if there is an incentive for doctors to recommend treatment and refer patients to a pharmacy in order to generate profits, regardless of what is in the best interest of the patients, or if doctors dispense drugs.

Several questions must be asked when the state is making its decision on this matter, questions with regard to ethics, safety, affordability and access, rational drug use, information and compliance:

Ethics: Is it a conflict of interest for physicians to sell the prescription drugs they prescribe? Is it important that the consumer has the freedom to choose from where to obtain drugs?

Safety: Is dispensing by pharmacists a safety net? Will prescriptions with errors, drug interactions or excessive drug use be prevented or minimized significantly by having the prescription pass through two qualified trained health professionals? How can quality be ensured for drugs dispensed by dispensing doctors versus pharmacist dispensed drugs?

Affordability: Will dispensing by doctors enhance competition and reduce prices? Do dispensing doctors prescribe more brand-name drugs or generic drugs compared to non-dispensing doctors?

Rational Drug Use: Will dispensing by doctors lead to over prescribing? Will dispensing by doctors narrow the therapeutic options by mainly limiting the drugs prescribed to those in their stock? The answers to all these will augur well for the separation of the dispensing and the prescribing practices.

I urge the Vincentian public, consumer bodies, the Pharmacy Council and Parliament to view that the patient’s freedom of choice is impinged because of his asymmetrical knowledge to that of the prescribing physician, the nature of the commodity and the patient’s lack of ability to choose what is prescribed, the general close proximity of the “physician’s own pharmacy” to their practising clinic. Doctors are viewed as authorities; patients do feel compelled to buy drugs from them, even when they know they can obtain the drugs from a pharmacy. This results in a closed market. Let’s enact the appropriate legislation to further protect the public.

Address comments about this article to tjreynold@yahoo.com or tel. 4543217 & 4562293