Separation of Diagnosing and Dispensing, the Korean Experience

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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

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• 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

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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

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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

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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)

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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

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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

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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

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Has the Policy made a success or fail?
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Influences on healthcare providersDoctors
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

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• Changes after the policy

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Number of Drugs Per Prescription
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, Prescription of Antibiotics
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Proportion of High-Cost Drugs
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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

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Number of Dispensing, According to Region and
Types
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????)
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(unit dispensing/day )
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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

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Continuity of Care, Patients with Diabetes
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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

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Probability of Discontinuing HT Therapy, 1999-2001
 
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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

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Consumer's benefits and cost
                                                
                                                  
                                                  
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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

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Health and drug industries Pharmaceutical
industry (contd)

• RD investment
• increased RD investment in 44 of the
  manufacturers and no change in 56
• the ratio of the total sales vs. RD investment
  down to 3.03 in 2000 from 3.7 in 1998
• RD 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

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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

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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

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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

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Voluntary Separation in Japan
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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

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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

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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

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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?

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