Transcript 임상진료지침에 대한 이해와 동향

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
Has the Policy made a
success or fail?
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
 Changes after the policy
Indicator
Change
rate of prescription per each claim
a little decreased
number of visits per each insurance claim
a little decreased
number of kinds of medicines per each claim
decreased?
number of days of medication per each visiting day
increased
number of days of injections per each claim
decreased
number of kinds of oral antibiotics
decreased
days of medication of oral antibiotics
slightly increased
number of kinds and the days of antibiotics injection
significantly decreased
medicines of high price
increased
cost of medicines per claim
significantly increased
Number of Drugs Per
Prescription
6.0 5.87
5.8
5.5
5.3
5.50
5.61
5.73
5.59 5.55
5.47
5.36 5.32 5.31 5.42 5.34
5.25
5.24 5.31
5.00
5.0
4.8
4.5
2000. 2001. Feb Mar Apr May Jun
May Jan
Jul Aug Sep Oct Nov Dec 2002. Feb Mar
Jan
%, Prescription of Antibiotics
%
60
55
50
54.70
52.47
53.81
55.06
52.53 53.43
49.25 48.51
47.94 48.39
48.20
44.13
45
45.49
49.66
46.11 45.98
40
2000. 2001. Feb Mar Apr May Jun
May Jan
Jul Aug Sep Oct Nov Dec 2002. Feb Mar
Jan
Proportion of ‘High-Cost’
Drugs
Jan 2000
Jan 2001
Jan 2002
24.23%
33.78%
28.67%
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”
Number of Dispensing,
According to Region and
Types
(unit: dispensing/day )
Large City
City
Rural
Total
Major
Hospital
Community
Total
149.3
89.2
-
91.4
98.8
88.8
24.6
22.9
10.6
72.2
74.3
75.3
121.5
93.4
23.5
73.1
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
Continuity of Care, Patients
with Diabetes
90
8 8 .7
89
8 8 .3
8 7 .9
8 8 .6
8 8 .3
8 8 .6
1999_1
2001_1
8 7 .9
88
8 6 .9
87
8 5 .9
86
85
85.2
84
83
84.2
85.5
85.8
85.5
85.3
84.6
8 4 .2
84.5
83.4
82.8
82
8 1 .9
81
80.4
80
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
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
Probability of Discontinuing HT Therapy, 19992001
Estimate
Variable
Sex
Female
Male
Age group
Odds ratio
95%
Confidence interval
1
0.170
0.007
Non-old
Old
Premium level
Standard
error
1.185
1.170 – 1.200
1
0.453
0.006
High
1.573
1.554 – 1.593
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
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
‘Voluntary’ Separation in
Japan
50%
40%
30%
20%
10%
0%
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
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?
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