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Separation of Diagnosing and Dispensing, the Korean Experience. Chang-yup Kim, MD, PhD, MPH School of Public Health, Seoul National University Seoul, Republic of Korea. CONTENTS Background Basic structure Influences on healthcare providers Changes in health care utilization
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Separation of Diagnosing and Dispensing, the Korean Experience Chang-yup Kim, MD, PhD, MPH School of Public Health, Seoul National University Seoul, Republic of Korea
CONTENTS • Background • Basic structure • Influences on healthcare providers • Changes in health care utilization • Consumer's benefits and cost • Health and drug industries • Lasing challenges and future
Background: Main Driving Forces • Widespread over- and mis-use of drugs e.g. antibiotics, steroid, injection, etc • Low quality, both at clinic and pharmacy • Too many ‘non-original’ drugs and doubtful quality • Limited rights of clients: information • Low transparency in drug business: large informal rebate
Background: Pre-history • Firstly stipulated in the revised Drug Law (1963) • Demonstration project in a city (May to Dec., 1984) • Dispute between pharmacist and doctor of traditional medicine on the dealing with herb drug, and resulting revision of the Drug Law (1994), in which separation of prescribing and dispensing (SPD) stipulated by 1999
Background: Policy Formulation • Discussion in the Health Reform Committee: Stepwise approach with 3 phases in 6 years (1998) • Organizing governmental committee (1998) to discuss among stakeholder • Debates (1998-2000) • Implementation of the policy (July, 2000) • Doctors strikes (Feb. – Nov. 2000)
Background: Main Issues • Which institutions: hospital? • Separation of drugs: therapeutic vs. OTC • Regional list of frequently prescribed drugs • Prescribing drug: generic vs. brand • Assuring equivalent efficacy of non-original drugs • Selling unit of OTC drugs: unit vs. pack
Current Structure • For all institutions, including hospital • Injections excluded • Therapeutic (61.5%) vs. OTC (38.5%), as of 2000 • Regional list not available • Prescribing drugs: brand name, in general • Usually bio-equivalence needed for substitution of drugs
Evaluation, too early? • A mixture of changes from diverse aspects • Some tangible, but mainly intangible changes • Quantitative/qualitative, short-term/long-term • Too early to have a conclusive evaluation result
Influences on healthcare providers:Doctor’s prescription • Some changes in the behaviors of prescription by opening the prescription to consumers and pharmacists • Doctors expected • to make prescription according to their clinical reasoning without consideration of any profit from drugs, and decrease misuse of drugs • to select medicines based on quality and/or effectiveness, resulting in more prescription of expensive drugs or drugs from major pharmaceutical companies
Jan 2000 Jan 2001 Jan 2002 24.23% 33.78% 28.67% Proportion of ‘High-Cost’ Drugs
Influences on healthcare providers :Pharmacists’ dispensing • Pharmacist expected to focus on dispensing, rather than on sales of OTC drugs. • Polarization of pharmacists and pharmacies • enlarging size of pharmcies • Concentration of prescription; 19.3% of the pharmacies have got over 80% of their total prescriptions from a particular medical institution and 15.6% of the pharmacies got 60 - 80% from a particular medical institution. • Pharmacists are performing well? • pharmacists’ services improved in general (KIHASA survey in 2002). • variable results from the in-depth interview; “the services of pharmacists have not been improved as much as consumers expected”
표 5). 약국 지역별, 유형별 처방조제건수 (단위: 하루평균 조제건수) 표 6). 약국 지역별, 유형별 처방조제건수 (단위: 하루평균 조제건수) 표 7). 약국 지역별, 유형별 처방조제건수 (단위: 하루평균 조제건수) Major Hospital Community Total Large City City Rural 149.3 89.2 - 91.4 98.8 88.8 24.6 22.9 10.6 72.2 74.3 75.3 Total 121.5 93.4 23.5 73.1 Number of Dispensing, According to Region and Types (unit: dispensing/day )
Changes in health care utilization • About 2,270,000 patients estimated to have converted to medical institutions from pharmacies • most significantly in the acute and chronic respiratory infections, followed by chronic diseases such as thyroid illness, diabetes and hypertension • a significant part of the patients who had visited pharmacies previously have moved to medical institutions • Increased continuity of care in chronic diseases • Improvement in the satisfaction with clinics and pharmacies • Dispensing available in 96.1% of first visited pharmacies
Negative Changes in Health Care Utilization • Decreased access • patients with chronic diseases have reduced visit to medical institutions, differently according to the socio-economic position. • probably resulted from increase of the cost, especially for the poorer groups • Reduced utilization in elderly • Concentration of health resources around large cities
Variable Estimate Standard error Odds ratio 95% Confidence interval Sex Female 1 Male 0.170 0.007 1.185 1.170 – 1.200 Age group Non-old 1 Old 0.453 0.006 1.573 1.554 – 1.593 Premium level High 1 Middle 0.011 0.004 1.180 1.162 – 1.199 Low 0.188 0.005 1.441 1.419 – 1.463 Copayment per medication day 1999 0.000 0.000 Copayment per medication day 2000 0.000 0.000 Probability of Discontinuing HT Therapy, 1999-2001
Consumer's benefits and cost • Additional benefit • decrease of misuse and overuse of drugs • improvement of the quality of prescription • to expand patients' right to know and prevention of adverse outcome of drugs through patient education by health care providers • Additional burden of expense • sharply increased expenditure of the health insurance. • after the financial stability countermeasure taken in July 2001, the medical cost turned to decrease while the expenditure from drug stores still was not decreased so much • Mostly intangible benefit vs. tangible cost
Consumer's benefits and cost 그림 3. 의약분업 비용의 증가와 감소
Health and drug industries:Pharmaceutical industry • Changes in the size of the market • continuously rising number of manufacturers of medicines • increasing turnover and total profit • Demand on OTC drug • small increase in 2000, and much large increase in 2001
Health and drug industries:Pharmaceutical industry (cont’d) • R&D investment • increased R&D investment in 44% of the manufacturers and no change in 56% • the ratio of the total sales vs. R&D investment down to 3.03% in 2000 from 3.7% in 1998 • R&D investment less than expected * increase of cost for marketing and manpower by about 60 • Foreign companies' market share • increasing share of multinational pharmaceutical companies in the field of therapeutic drugs
Health and drug industries:Health care facilities and human resources • Increase of medical institutions • 21,834 clinics and 724 hospitals in March 2002 from 18,000 clinics and 638 hospital in June 2000, which 21.3% and 13.5% increase respectively • Impact on the financial status of hospitals • not conclusive • Distribution of manpower • shift of health workers from public sector to private • 9.7% of pharmacists working at health centers moved for the first year, with the number of pharmacists working at drug stores being increased
Health and drug industries:Pharmacist and pharmacies • No change in the number of pharmacies • 18,363 in 1999, and 18,372 in 2001 • Changes in main function • increase of turnover by 62% • distribution of function, in terms of turnover • dispensing (51.31%) • sales of OTC drugs (30.64%) • dispensing for medical aid prescription (6.67%) • dispensing of oriental medicines (4.31%) • nutrient supplement (2.23%) • sales of any other products than drug (5.02%) • New problems • purchasing cost for the preparation of drugs for prescriptions • concentration of prescription on a particular drug store by ‘prearranged consultation’ between drug stores and medical facilities
Lasting challenges: Proposal for voluntary separation • Proposed by the Korean Medical Association • Lessons from other countries • for the successful voluntary separation, the economic incentive for doctors should be at least more than the present level in order to maintain or increase the rate of separation. • health care expenditure to be more increased • Current situation • still no clear frame scheme with different opinions among stakeholders • Prospect • not acceptable by pharmacists, if allow doctors to make a dispensing otherwise not touched • weakening of the separation, even with strong incentives
Lasting challenges:Proposal for functional division within institution • Proposed by the Korean Hospital Association • hospitals can have pharmacists for outpatients and make the dispensing and separation is applied only to clinic without pharmacist • Lessons from other countries • no reason for sending prescription outside the hospitals, and the medical institutions with pharmacists not issuing prescription slips for outside dispensing • Suspicious of accomplishing the original purpose of the policy • Prospects • Actually no separation within a institution, due to power relationship among health professionals and management • expected to accelerate concentration of patients on the hospitals, to make clinic less competitive due to inconvenience • debatable between hospital sector and clinic sector
Lasting challenges: Improvement of the policy • Behavioral change in prescription, into more cost-effective manner • Quality improvement in dispensing • Inspection into violation of regulation and rules: illegal prescription and dispensing, prearranged consultation, etc. • Facilitation of the use of generic drugs • Quality improvement of drug • Others
Conclusions • Benefit • Early signs, but not fully realized • Much intangible benefits • Cost • Short-term cost realized, but not fully controlled • Consumers’ adaptation • Transitional cost? • New way? • Alternative scheme: not realistic • A new ‘corporatism’: improved governance, consumers’ sovereignty, and professional roles
Lessons • Why reform? • Evidences • Who drive? • Professional leadership • Consumers’ sponsoring • Partnership: “cause group” • How? • Political commitment • Public relationship and partnership Who will support you and why?
