FACTORS INFLUENCINGOUTPATIENT PHYSICIANPRESCRIPTION PRACTICIES INGEORGIA

7/28/2019 FACTORS INFLUENCINGOUTPATIENT PHYSICIANPRESCRIPTION PRACTICIES INGEORGIA

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GEORGIAN INSURERS ASSOCIATION

FACTORS INFLUENCING

OUTPATIENT PHYSICIAN

PRESCRIPTION PRACTICIES IN

GEORGIAFinal Report

June 2012


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Table of Contents

SECTION I: ACCOMPLISHMENTS ............................................................................................................2Objective 1: Factors Influencing Prescription Practices ....................................................................2

Objective 2: Study Rational Prescription Practices ...........................................................................3

Objective 3: Define Economic Impact of Prescription Practices.......................................................4

Objective 4: Advocacy and Public Awareness ...................................................................................4

Position Papers......................................................................................................................................4

Public Discourses: ................................................................................................................................. 4

TV coverage...........................................................................................................................................5

Radio Coverage ..................................................................................................................................... 5

Newspapers .......................................................................................................................................... 5

SECTION II: CHALLENGES .........................................................................................................................5

SECTION III: ANNEXES ...............................................................................................................................6

ANNEX 1: FACTORS INFLUENCING OUTPATIENT PHYSICIAN PRESCRIPTION PRACTICIES IN GEORGIA6

ANNEX 2: FACTORS INFLUENCING OUTPATIENT PHYSCIAIN PRESCRIPTION PRACTICIES IN

INSURANCE SETTINGS................................................................................ Error! Bookmark not defined.

ANNEX 3: RATIONALIZATION OF PHARMACEUTICAL EXPENDITURE , POSITION PAPER .............. Error!

Bookmark not defined.

ANNEX 4: POPULATION SURVEY .............................................................. Error! Bookmark not defined.

ANNEX 5: POSITION PAPER ...................................................................... Error! Bookmark not defined.


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SECTION I: ACCOMPLISHMENTS

Objective 1: Factors Influencing Prescription Practices

In the reporting period the following activities have been completed under the grant:

Literature Review the expert team has reviewed literature published internationally. The

review guided formulation and design of the activities planned.

The project has organized the Focused Group Discussion (FGD) with the primary health care

physicians to obtain qualitative information regarding factors influencing prescribing practice in

Georgia. Based on the FGD is became clear that only qualitative information was not sufficient

to find out tendencies, therefore the team has prepared all required tools to conduct

quantitative survey on Factors Influencing Prescription practices in Georgia.

The above mentioned survey was not planned in the original project proposal. A questionnaire

was developed, specifically for the purposes of the survey. The questionnaire is divided into sixdifferent sections. The first includes questions about the demographic characteristics of the

person answering; the second is designed to investigate the determinants of physician

prescribing behavior and their main sources of information; the third reflects their opinion

about the cost of pharmaceuticals to the patient; the fourth section focuses on attitudes

towards the prescription of generics; the fifth section reflects attitudes towards new

pharmaceutical products; the last section is about adverse drug reactions and safety. In total,

the questionnaire included 30 closed questions. It was piloted to a group of 10 physicians in the

period of June 01 to June 30 of 2011. The physicians who participated in the pilot study made

significant comments towards the improvement of the instrument and all of their

recommendations were taken into consideration and were incorporated in the final

questionnaire.

The survey sampling methodology used was not a classical random sampling. The sampling

methodology proposed the following steps:

Firstly the settlements or cities have been selected. The researchers selected Tbilisi, a

capital as one major administrative unit as well as all regional centers and randomly

selected one district in each region.

Secondly all functional medical facilities, offering outpatient services to the population

in selected geographical areas were included in the survey sample.

Thirdly as the research team was unable to obtain official information about number of

practicing physicians in each selected facility from official sources, the decision has been

made to survey everyone being present at the facility on the day of the survey.

In total 619 physicians in 65 selected institutions have been conducted. The team managed to

finalize field work and data analysis. The final report is attached to this report ( Annex I)


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Objective 2: Study Rational Prescription Practices

Two types of surveys were administered by GIA to assess rational prescription practices:

Rational Drug Use in Insurance schemes

This survey aimed at studying the patterns of drug prescription and use in insurance setting,

identification of problematic areas and will guide the development of the recommendations related to

overall policy changes/interventions, as well about the ways the insurance industry can deal with

irrational drug use and improve efficiency of pharmaceutical benefit management.

As Georgia does not practice mandatory prescribing and there is no ay other source available to be used

for assessing rational drug use, the researchers were forced to focus only on insurance industry, where

physician prescriptions are required for pharmaceutical claims reimbursement.

For this purpose, only two insurance companies, having digitalized claims information and being willing

to take part in the research, were selected. The claims data from both companies have been obtainedfor the period of January, 2011 July2011 and claims selected using random sampling methodology.

In total claims for 83,250 insurance cases were analyzed using the WHO prescription indicators (Table 1).

These indicators are highly standardized, do not need national adaptation, and are recommended for

inclusion in any drug use study using indicators. They do not measure all important aspects of drug

utilization as this would require more intensive methodologies and more expenses and varied sources of

data. Instead, the core indicators provide a simple tool for quickly and reliably assess a few critical

aspects of pharmaceutical use in primary health care. Results with these indicators should point to

particular drug use issues that need examination in more detail. These indicators are the minimum set

of measures to be calculated during the drug use survey.

Table 1: WHO Prescription Indicators

Core drug use indicators

Average number of drugs per encounter

Percentage of encounters with a generic prescribed

Percentage of encounters with antibiotic prescribed

Percentage of encounters with injection prescribed

The core prescribing indicators do not require the collection of any information on signs and symptoms.

Because the samples of clinical encounters cover broad spectrum of the health problems, the core

prescribing indicators measure general prescribing tendencies independent of specific diagnoses.Admittedly, many critical questions in drug use have to do with whether health care providers follow

appropriate diagnostic procedures and whether they select products and dosage schedules to fit

underlying health problems. However, determining the quality of diagnosis and evaluating the adequacy

of drug choices is a complex undertaking in practice, and beyond the scope of the core indicators.

Results of the Study are attached to the Final Report.


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Population Based Survey

The survey tool was designed to collect information regarding four major aspects:

Health status self assessment

Who prescribes medicines tendencies

Drug purchasing practices

Drug administration practices

The survey was administered in October-November, 2011

The final presentation of the survey results are attached.

Objective 3: Define Economic Impact of Prescription Practices

GIA studied the economic impact of prescription practices using secondary data from the Survey of

Price, Access and Affordability of medicines in Georgia. The team managed to calculate the costs of

standard treatment protocols of four diseases using brand name medicines and equivalent low cost

generics.

Results of economic analysis were included in the presentation of Impact of Prescription Practices on

access to health Service in Georgia .

Objective 4: Advocacy and Public Awareness

Position Papers

Two position papers were prepared during the project.

1. Rationalization of Pharmaceutical Expenditures in Georgia ( interim position paper)

2. Generating Resources to Ensure Financial Accesses to Quality Health Services

Public Discourses:

Two public discourses were organized around pharmaceuticals. A wide range of stakeholders including

public, private (health providers, Insurance companies, pharmaceutical industry), professional

associations and civil society participated in public discourses.


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A special presentation of the Position Paper II was organized for journalists on May 30, 2012 to ensure

that mass media understands the main challenges and give a wide coverage to these issues. As a follow-

up to this event, the Business Courier at Rustavi2 focused twice within a week on issues of generating

resources for affordable healthcare through reducing drug expenditures: on 01.06.2012 inviting the CEO

of Archimedes Global Georgia and on 07.06.2012 discussing measures to be taken with Devi

Khechinashvili, Chairman of GIA.

TV coverage

1. http://1tv.ge/video/13137

2. http://1tv.ge/video/12747

3. http://www.rustavi2.com/news/programs_rug.php?l=31

23.04.12, 01.06.12, 07.06.12.

Radio Coverage

Three radio talk shows were organized on radio Imedi (see web links below)

1. http://soundcloud.com/insurersassociation/29-may-radio-imedi2. http://soundcloud.com/insurersassociation/28-may-radio-imedi

3. http://www.palitratv.ge/gadacemebi/mkurnali/16584-qradiomkurnaliq-jandacvis-sferoshi-

arsebuli-problemebi.html

Newspapers

http://www.kvirispalitra.ge/public/11953-saqarthvelo-yvelaze-qtsamalthmoyvareq-qveyana.html

Axali Versia on May 16, 2012

SECTION II: CHALLENGES

Ability of the Insurance companies to provide pharmaceutical claims databases that are

standardized and allow sorrow analysis. This aspect limited research team o focus survey only

two insurance companies.

Delays in implementation of some activities planned under the advocacy and public awareness

component was due to the change of leadership at the Ministry of Labor, health and Social

Affairs.


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SECTION III: ANNEXES


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20

June 2012

FINF

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PRA

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11

CTORSUENCING

PATIENT

YSICIAN

CRIPTION

TICIES IN

ORGIA


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Introduction

Over the past decade, pharmaceutical expenditure has risen rapidly in Georgia and this has been a

reason for concern to policymakers. Pharmaceutical expenditure accounts, on average, for about 10% of

the Gross Domestic Product (GDP). It is notable however that its growth in real terms is higher than thegrowth rate of total healthcare expenditure or the growth rate of GDP. Alongside the concern regarding

the growth of pharmaceutical expenditure, there is also an increasing concern regarding irrational,

inappropriate, or sometimes even harmful prescribing.

Ensuring appropriate prescribing is a major challenge for the health service. Inappropriate prescribing

has both clinical and cost implications, which may be substantial1. Factors implicated in inappropriate

prescribing, and methods for improving prescribing patterns have been the subject of a considerable

body of research that has highlighted the complexity of this topic2.

Prescribing involves a complex process3

of sifting information from various sources and balancing a

range of personal, social, and logistical influences, in addition to those that are purely medical and

pharmacological. In the case of new drugs, practitioners are trying to balance a range of factors, such as

potential side effects, long-term effects, and the range of therapeutic indications, for which relatively

little information is available and around much of which they may have little or no practical experience.

Under such circumstances prescribing may be more an act of faith than a rational process.

Moreover, there is also an anecdotal evidence about over and misuse of pharmaceutical products. The

consequence of the above can be the loss of health and quality of life benefit for patients and society

and the increase of health care expenditure. Thus, for health and economic reasons, it is important to

follow the recommended optimal and established drug prescription guidelines.

It is obvious that there is call for work that will take account of the reasons behind individual prescribing

decisions.

Survey Methodology

A questionnaire was developed, specifically for the purposes of the survey. The questionnaire is divided

into six different sections. The first includes questions about the demographic characteristics of the

person answering; the second is designed to investigate the determinants of physician prescribing

behavior and their main sources of information; the third reflects their opinion about the cost of

pharmaceuticals to the patient; the fourth section focuses on attitudes towards the prescription of

generics; the fifth section reflects attitudes towards new pharmaceutical products; the last section is

about adverse drug reactions and safety. In total, the questionnaire included 30 closed questions. It was

piloted to a group of 10 physicians in the period of June 01 to June 30 of 2011. The physicians who

1Soumerai SB. Factors influencing prescribing.Aust J Hosp Pharm 1988; 18(suppl): 9-16.

2Bradley CP. Uncomfortable prescribing decisions: a critical incident study. BMJ 1992; 304: 294-296;

Allery LA, Owen PA, Robling MR. Why general practitioners and consultants change their clinical practice: a critical incident

study. BMJ 1997; 314: 870-874.3

Drage M, Wakeford R, Wharton A. What do general practitioners think changes their clinical behaviour? Educ Gen Pract1994;

5: 48-53.;


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participated in the pilot study made significant comments towards the improvement of the instrument

and all of their recommendations were taken into consideration and were incorporated in the final

questionnaire.

The survey sampling methodology used was not a classical random sampling. The sampling methodology

proposed the following steps:

Firstly the settlements or cities have been selected. The researchers selected Tbilisi, a capital as

one major administrative unit as well as all regional centers and randomly selected one district

in each region.

Secondly all functional medical facilities, offering outpatient services to the population in

selected geographical areas were included in the survey sample.

Thirdly as the research team was unable to obtain official information about number of

practicing physicians in each selected facility from official sources, the decision has been made

to survey everyone being present at the facility on the day of the survey.

In total 619 physicians in 65 selected institutions have been conducted.

The study limitation apart from the above mentioned was the lack of distinction between primary andsecondary care physicians, which would have allowed a better comparison with other studies in this

field. However, this parameter was not taken into account during the study design because Georgia has

no gate-keeping system and patients have free access to every physician of every specialty and level of

care.

Survey Findings

Demographic Characteristics of Respondents

619 physicians participated in the study 54% were male and 46% female. As indicated in Table 1, more

than one third of the participants (37%) were between 4150 years of age.

Table 2: Age and Gender Distribution of Respondents

Age Number % Female Male


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(Table 2). A larger percentage of respondents named International conferences (26%), new text books

(22%) and short-term courses (18%) as the most frequently used sources for continuous professional

development (Table 3).

Table 3: Respondents by Specialty, Age Groups and Practice Location

Age Groups Practice Location

61 Total % Tbilisi Regions

FP/GP 2 33 65 45 7 152 24% 85 67

Internist 3 17 24 31 19 94 15% 45 49

Pediatrician 1 10 36 26 16 89 14% 36 53

Gynecologist5 1 12 20 11 1 45 7% 16 29

Cardiologist 1 4 6 11 6 28 4% 16 12

Neurologist 0 9 14 8 11 42 7% 23 19

Endocrinologist 2 5 10 4 2 23 4% 14 10

Surgeon 5 9 15 22 10 61 10% 23 38

Other 3 15 46 26 14 104 16% 45 61

About a third (33%) of surveyed physicians who prescribe medicines on a daily basis work in the

inpatient departments of hospitals, 30% at policlinics and the remaining in other outpatient settings.

Table 4: Most Frequent Sources of Continuous Professional Development

Most Frequent Sources of Continuous Professional Development Tbilisi Regions Total

International Conferences 23% 28% 26%

New Text Books 20% 23% 22%Short-term Courses 24% 17% 20%

Scientific Publications 13% 22% 18%

Local Conferences/Workshops 13% 5% 9%

Other 6% 6% 6%

In terms of computer acquaintance Tbilisi physician cohort appears to have a slight advantage (Table 4).

However, it needs to be noted that physicians in both, capital and regions use internet to find out

information about new treatment schemes.

Table 5: Use of Internet as a source of learning about new treatment schemes

Use of Computer per month Total %

Tbilisi Regions Total Tbilisi Regions Total

Never Use 7 34 41 3% 10% 7%

About 2 hours 65 109 174 23% 33% 28%

About 5 hours 55 72 127 20% 22% 21%

>5 hours 153 119 272 55% 36% 44%


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Characteristics of drug selection for treatment

As mentioned earlier, the first part of the questionnaire was intended to investigate the criteria which

physicians take into consideration when making prescribing decisions and their sources of information

regarding advances in pharmaceuticals.

As indicated in Table 5, clinical effectiveness is the most important factor both in the capital and regions,

reaching overall 24.1% defining prescriptions. Next most frequently considered sources for prescription

decision are clinical guidelines and own experience. Treatment cost effectiveness is less taken into

account by Physicians (10.7%). Findings also revealed that physicians rarely consider availability of drugs

(4.3%) on a local market while prescribing treatment.

Table 6: Characteristics of drug selection for treatment

Considerations taken into account for prescribing Tbilisi Regions Total

Evidence Based clinical effectiveness 25,8% 22,7% 24,1%

Clinical Guidelines 24,4% 21,0% 22,6%

Own experience 17,0% 22,8% 20,2%

Treatment cost effectiveness 10,5% 10,8% 10,7%

Drug Price 5,9% 8,7% 7,4%

Country of Production 7,4% 5,8% 6,5%

Availability in local market 5,0% 3,7% 4,3%

Patient request 1,4% 1,5% 1,4%

Other 1,1% 0,6% 0,9%

Colleagues advise 0,5% 1,1% 0,8%

Advice of the Pharmaceutical Rep 0,8% 0,6% 0,7%

Most advertised in media 0,1% 0,7% 0,5%

Cost of Medicines as a factor of drug choice

Not at all Important 2,2% 3,0% 2,6%

Not very Important 12,0% 8,4% 10,0%

Important 30,4% 33,2% 32,0%

Highly Important 55,4% 55,4% 55,4%

Patient's "Insured Status" influences Prescriptions

Expensive medicines 0,7% 1,0% 0,8%

Relatively cheap medicine 8,4% 12,6% 10,8%

Foreign products 5,2% 6,3% 5,8%

Locally produced medicines 6% 8% 7%

Insurance Company Formulary 24% 27% 26%

National EDL 7% 9% 8%


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Does not influence prescription 48% 37% 42%

Sources referred for justifying prescription decisions

Published articles in Medical Journals 9,8% 9,3% 9,5%

Medical textbooks 16,8% 22,6% 20,0%

Conference materials 18,1% 16,1% 17,0%

National Guidelines 17,4% 19,9% 18,8%

International guidelines 24% 14% 19%

Pharmaceutical sales Reps 11% 16% 14%

other 3% 2% 2%

Reasons for searching information from the above sources on prescription choice

Indications 21,9% 22,9% 22,4%

Dose 15,7% 19,4% 17,7%

Form 1,8% 0,9% 1,3%

Country of Production 6,5% 5,2% 5,8%

Pharmaceutical Characteristics 14% 14% 14%Interactions with other medicines and substances 14% 11% 12%

Contraindications 10% 10% 10%

Adverse drug effects 13% 13% 13%

Price 3% 3% 3%

Physicians derive information to guide and justify their prescription choices mainly from medical

journals, medical textbooks, proceedings of medical conferences, pharmaceutical sales representatives,

guidelines and the internet. Specifically, Georgian physicians rely more on medical textbooks and

guidelines (around 38%) and less on pharmaceutical representatives (14%). On the other hand,

conference materials, the latter being mainly financed by pharmaceutical market and pharmaceutical

representatives are preferred as an information source by 31%.

Physicians are looking for information on the above sources mainly regarding the indications,

recommended dose of drugs, forms, and country of production, their potential side effects,

pharmaceutical characteristics, contraindications and prices.

Attitudes of physicians towards generic prescribing

Table 6 contains information regarding the responses of physicians in relation to generic drug use. It is

noteworthy that more than half of surveyed doctors in Georgia find generic drugs excellent or

satisfactory in terms of efficacy, safety and effectiveness (98%, 95.2% and 69.7% respectively). About

78% of Georgian Physicians find generic drugs cheaper or same price to their branded ones. However,

only 16.5% of them prescribe generic drugs.


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Table 6: Attitudes of physicians towards generic prescribing

Tbilisi Regions Total

Perceived quality of generic drugs in comparison to their branded ones

Excellent 6,0% 6,7% 6,4%

High quality 50,2% 54,1% 52,3%

Satisfactory 42,7% 36,5% 39,3%

Rather bad 0,7% 2,7% 1,8%

Bad 0% 0% 0%

Perceived safety of generic drugs in comparison to their branded ones

Very Safe 3,0% 3,6% 3,3%

Safe 71,3% 66,6% 68,7%

Average 20,9% 25,0% 23,2%

Unsafe 4,9% 4,8% 4,8%

Perceived clinical effectiveness of generic drugs in comparison to their branded ones

Incomparably more effective 2,6% 2,7% 2,7%

Comparably effective 24,9% 34,5% 30,3%

Equally effective 38,1% 35,7% 36,8%

Less effective 34,0% 26,8% 30,0%

Not Effective 0,4% 0,3% 0,3%

Cost of generic drugs in comparison to their branded ones

More Expensive 1,9% 2,8% 2,4%

Relatively Expensive 18,4% 20,9% 19,7%

Same Price 9,0% 14,1% 11,8%

Relatively Cheep 68,9% 58,3% 63,1%

More Cheep 1,9% 4,0% 3,0%

Prescribing Practice

Original Brands 64,5% 55,3% 59,5%

Generics 13,4% 19,1% 16,5%

Brand Generics 22,1% 25,5% 24,0%

Attitudes of physicians towards new drugs

Information regarding attitudes in relation to new drugs is presented in Table 7. The majority, 75%, of

physicians in Georgia believe that a higher price imply better patient outcomes. The perceptions of 60%

of physicians are that new drug more effective. Finally, regarding the sources of information about new

product launches, these mainly include internet, printed marketing material, scientific articles,

congresses and sales representatives and secondarily scientific medical societies.


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Table 7: Attitudes of physicians towards new drugs


High Price of new drugs as an indication of high clinical effectiveness

Fully Agree 3% 3% 3%

Agree 16% 23% 20%

Partially Agree 58% 52% 55%

Do not Agree 22% 19% 20%

Strongly Disagree 1% 3% 2%

Perceived clinical effectiveness of new drugs

Clearly more effective 14% 16% 15%

Rather more effective 46% 45% 45%

Do not differ significantly 38% 33% 35%

Do not differ at all 3% 6% 5%

Source consulted in order to get information about new drugs

Medical Journals 7% 10% 9%

Scientific articles 16% 15% 15%

Medical Congresses. Conferences 17% 12% 15%

Pharmaceutical Sales Reps 11% 11% 11%

Printed Marketing Material 15% 16% 16%

Colleagues 2% 1% 1%

Professional Associations 5% 7% 6%

Internet 28% 27% 27%

Attitudes of physicians towards drug safety

Finally, Table 8 presents information regarding physician attitudes towards safety issues. As indicated by

the finding. Side effects appear in both countries to be a major cause of prescription choice

modification, as more than 90% of doctors declare that they change their prescription patterns in cases

of side effects. It is also noteworthy that the majority of doctors do not inform the authorities about

their own cases of side effects. Only 1% of physicians report to Ministry of Health and 14% to the clinic

administration, while 33% of physicians report directly to pharmaceutical representatives and 43% share

with colleagues.

Table 7: Attitudes of Physicians towards drug safety


Appearance of ADRs affects prescribing decision

Always 99% 99% 99%

Sometimes 1% 1% 1%


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Never 0% 0% 0%

Reaction to ADR appearance

Clinic Administration 8% 20% 14%

Ministry of Health 1% 1% 1%

Pharmaceutical Representative office 37% 29% 33%

Manufacturer Headquarter 2% 1% 2%

Pharmacy that sold the drug 1% 2% 2%

Just inform colleagues 44% 43% 43%

Do not react at all 7% 4% 5%

Analysis

Pharmaceutical market appears as a main financier of the physicians continuous medical education

(CME) activities

According to the present analysis, the largest proportion of participants has more than 20 years of

practical experience, thus representing more experienced sample. More than half of Physicians upgrade

their professional education by attending local or international conferences and short-term course. It is

notable that the Georgian Government stopped financing of CME activities for last couple of years. The

state funding is no longer available neither for participation in local or international conferences, or for

short-term courses in support of physicians continuous education. The professional associations also

fall short to meet member requirements; therefore these types of educational events at a lesser degree

are financed privately by doctors and more frequently by Pharmaceutical companies. Thus thepharmaceutical market using their financial leverage in support of CME may potentially influence

physicians prescription practices.

Georgian Physicians are computer literate and use internet as a main source of information

Use of internet as a most frequently used source for CME was named by majority of surveyed

physicians. Insignificant difference was observed between the physicians practicing in the capital and in

the regions. About half of physicians spend more than five hours in order to obtain new information

from internet.

Treatment cost effectiveness and cost of medicines rarely influence prescription decisions

Absolute majority of Georgian physicians consider drug cost to be highly important and important factor

to be well thought-out for prescription purposes, but only few percent of physicians take it less or more

seriously into consideration when prescribing.


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Georgian Physicians tend to use national and international guidelines for justification of prescription

decisions

The results of our study show that one third of physicians use national and international guidelines tojustify their drug selection decision. The policy makers can build on this finding and foster wider use of

guidelines in order to improve treatment clinical and cost effectiveness.

Patients Insurance Status does not influence prescription decisions

Study revealed that in more than half of cases patients insurance status doesnt effects prescription

decision. While ignorance of insurance status contributes towards increased pharmaceutical costs in

general, the problem is the way the pharmaceutical benefits are designed and managed by the industry.

Insurance status is considered in those cases where pharmaceutical benefit is reimbursed by the

insurance company against specific formulary and/or national essential drug list. Physicians compliance

with established rules of using formularies should be used as an opportunity by the policy makers,

including the insurance industry.

Physicians attitude towards generic drugs is positive, but rarely prescribed

It is noteworthy that more than half of surveyed doctors in Georgia find generic drugs excellent or

satisfactory in terms of efficacy, safety and effectiveness and find them cheaper to their branded ones.

Moreover, majority of them consider cost of medicines as an important factor for prescribing decision,

but in a reality generic drugs are rarely prescribed, physicians do not prescribe generic drugs as a means

to curtail expenditure.

Given behavior is not influenced by the lack of knowledge and/or information and/or negative attitude,

rather by the possible incentives in the market. Low generic drug use in this country can be explained

through the combination of several factors. The given research was not able to detect direct incentive

factors guiding such behavior, however based on the findings as well as health sector design and

performance, one can name selected indirect factors such as: poorly defined government stewardship

and regulatory role, namely absence of well formulated pharmaceutical policy, loosely regulated

pharmaceutical sector, no restrictions for Pharmaceutical marketing, few treatment guidelines and no

enforcement for utilization, diminishing role of the state in health human resource management and

development, including post diploma and continuous medical education and pharmaceutical market

becoming major financier of human resource development activities. Furthermore, in Georgia there are

no financial incentives to motivate physicians to prescribe generics and to promote the generic market.

Physicians believe that a higher price imply better patient outcomes

The study found that the majority of physicians in Georgia believe that a higher price imply better

patient outcomes. The perceptions of physicians are that new drugs are more effective. In case of new

drugs, pharmaceutical market appears to be the most powerful source of information. About half of


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phsycians receive information about new drugs from pharmaceutical sector financed conferences, sales

representatives and drug marketing materials. These data are consistent with those from other studies,

where it has been also shown that pharmaceutical sales representatives are highly influential on

decisions to prescribe new drugs45

.

No government recognized authority is considered by physicians to be responsible for drug safety and

pharmacovigilance

Even though adverse drug reactions may not appear very often, they do have a profound effect on a

physician prescribing patterns, so doctors seek information in order to be protected and prepared. It is

notable, however, that when they encounter such problems physicians rarely inform the authorities

accordingly, perhaps because they either they do not know who is responsible authority or do not want

to acknowledge the fact that their patients had side effects. According to the finding of the study

physicians mostly inform pharmaceutical companies and share information with colleagues.

Conclusion

Although this study is based around prescribing, the results may have a wider validity and speak to a

more general phenomenon, which needs to be further explored. Focusing on the issues raised around

prescribing it is suggested to promote cost effective prescribing. Efforts should focus on incorporating

cost-consciousness more uniformly into prescribers reasoned actions through strategies implemented

by both, state and insurance industry.

4Prosser H, Almond S, Walley T: Influences of GP's decision to prescribe new drugs the importance of who says what. Fam

Pract2003, 20:61-68

5Jones M, Greenfield S, Bradley C: Prescribing new drugs: qualitative study of influences on consultants and general practitioners. BMJ 2001,

323:1-7.


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Introduction

FACTORS INFLUENCING

OUTPATIENTPHYSICIAN

PRESCRIPTION

PRACTICIES INGEORGIA

2011

Final Report


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Drug utilization research is an essential part of pharmaco-epidemiology as it describes the extent,

nature and determinants of drug exposure6. The World Health Organization (WHO) in 1997 defined

drug utilization as the marketing, distribution, prescription and use of drugs in a society, with special

emphasis on the resulting medical, social and economic consequences7.Drug use is a complex process. In

any country a large number of socio-cultural factors contribute to the ways drugs are used. The

complexity of drug use means that optimal benefits of drug therapy in patient care may not be achieved

because of underuse, overuse or misuse of drugs. Inappropriate drug use may also lead to increased

cost of medical care, antimicrobial resistance, adverse effects and patient mortality.

Essential drugs offer a cost-effective solution to many health problems8. They should be selected with

due regard to disease prevalence, be affordable, with assured quality and be available in appropriate

dosage forms. Prescribers can only treat patients in a rational way if they have access to an essential

drug list and essential drugs are available on a regular basis9.

To assess the scope for improvement in rational drug use in outpatient practice, the World Health

Organization (WHO) has formulated a set of core drug indicators. The core prescribing indicators

measure the performance of prescribers. Based on these indicators studies have been carried out in

number of developing countries. Since no such study has been carried out in Georgia, we wanted to

measure prescribing indicators in outpatient clinics to obtain data for promoting rational drug use.

Purpose of the Survey

This survey aims at studying the patterns of drug prescription and use in insurance setting, identification

of problematic areas and will guide the development of the recommendations related to overall policy

changes/interventions, as well about the ways the insurance industry can deal with irrational drug useand improve efficiency of pharmaceutical benefit management.

Methodology

As Georgia does not practice mandatory prescribing and there is no ay other source available to be used

for assessing rational drug use, the researchers were forced to focus only on insurance industry, where

physician prescriptions are required for pharmaceutical claims reimbursement.

66Sjoqvist F, Birkett D. Drug Utilization. In: Bramley DW editor. Introduction to Drug Utilization Research. (WHO booklet) New York: WHO office

of publications; 2003. P.76-847

WHO Expert Committee. The Selection of Essential Drugs, Technical Report Series no. 615. Geneva: World Health Organization, 19778

Quick JD, Hogerzeil HV, Velasquez G, Rago L. Twenty-five years of essential medicines. Bull W H O 2002; 80 : 913-9149

International Network for Rational Use of Drugs and World Health Organization. How to investigate drug use in health facilities: Selected

drug use indicators. EDM Research Series No. 7 [WHO/DAP / 9 3 . 1 ] . Geneva : World Health Organization, 1993


21/37

For this purpose, only two insurance companies, having digitalized claims information and being willing

to take part in the research, were selected. The claims data from both companies have been obtained

for the period of January, 2011 July2011 and claims selected using random sampling methodology.

In total claims for 83,250 insurance cases were analyzed using the WHO prescription indicators (Table 1).

These indicators are highly standardized, do not need national adaptation, and are recommended forinclusion in any drug use study using indicators. They do not measure all important aspects of drug

utilization as this would require more intensive methodologies and more expenses and varied sources of

data. Instead, the core indicators provide a simple tool for quickly and reliably assess a few critical

aspects of pharmaceutical use in primary health care. Results with these indicators should point to

particular drug use issues that need examination in more detail. These indicators are the minimum set

of measures to be calculated during the drug use survey.

Table 8: WHO Prescription Indicators

Core drug use indicators

Average number of drugs per encounterPercentage of encounters with a generic prescribed

Percentage of encounters with antibiotic prescribed

Percentage of encounters with injection prescribed

The core prescribing indicators do not require the collection of any information on signs and symptoms.

Because the samples of clinical encounters cover broad spectrum of the health problems, the core

prescribing indicators measure general prescribing tendencies independent of specific diagnoses.

Admittedly, many critical questions in drug use have to do with whether health care providers follow

appropriate diagnostic procedures and whether they select products and dosage schedules to fit

underlying health problems. However, determining the quality of diagnosis and evaluating the adequacy

of drug choices is a complex undertaking in practice, and beyond the scope of the core indicators.

Study Limitation

Any drug utilization study based on WHO core drug use indicators has limitations. Determining the

quality of diagnosis and evaluating the adequacy of drug choices is beyond the scope of the prescribing

indicators. However the present study provides important useful baseline data which will be used for

comparison when in future any such drug utilization sty will be carried out.

Results

A total of 282,398 drugs were prescribed for 83,250 encounters, giving an average of 2.9 per

encounter, which is higher than internationally accepted 2.0 drugs per encounter. One drug was


22/37

prescribed in 25%, two drugs in 24% and in 52% of encounters three and more drugs were prescribed

(Table 2). The range of drugs per encounter varied from 1 to 31.

Table 9: Total Number of Drugs Prescribed per Encounter

Number of Drugs Prescribed Per

Encounter

Total %

1 23 912 25%

2 23 532 24%

3 20 149 21%

>3 28 908 30%

Generic prescribing appears not to be a dominant practice (Table 3) as in 96% of encounters medicines

are prescribed by brand names.

Table 10: Percentage of drugs prescribed by generic name

%

Brand 96%

Generic 4%

The percentage of encounters with antibiotics was 12.8%. A single antibiotic was prescribed in 80% of

encounters, two antibiotics (16%) and in remaining three antibiotics (Table 4). Antibiotics are mainly

prescribed by brand name (96.8%) and generic prescription was only 3.2%.

Table 11: Percentage of encounters with an antibiotic prescribed

Number of encounters %One antibiotic 23 493 80%

Two antibiotics 4 582 16%

Three antibiotics and more 1 112 4%

Antibiotic prescription practices differ across the country. Highest usage has been recorded in Guria

(31.8%), Shida Kartli (20.8%) and Imereti (20.2%) regions, while the lowest antibiotic prescription was

recorded in Samtskhe-Javakheti region (10.2%).

Table 12: Percentage of encounters with injection drugs prescribed

Number of encounters %

Injection drugs 15 038 5%


23/37

Other drugs 267 361 95%

Injection drugs prescribed by Brand Name 13 248 88%

Injection Drugs prescribed by Generic Name 1 789 12%

The study revealed that injection drug use is low in insurance setting and represents only 5% of

encounters (Table 5). Only 12% of injection drugs are prescribed by generic name. Injection drug use is

highest in Guria (17.1%) and Samtskhe -Javakheti (11.2%) regions, while the lowest has been recorded in

Tbilisi 7.4%.

The analysis also shows potential financial implications of the given practice. More specifically, average

price of generic medicines paid by insurance is 60% cheaper of brand name medicines and generic

antibiotics 63% cheaper of their equivalent brand antibiotics (Table 5).

Table 13: Average price of Medicines

Average Price per prescribed drug in GEL

Brand 15,58

Generic 6,22

Brand Antibiotic 23,76

Generic Antibiotic 8,78

Discussion

Irrational use of drugs may lead to:

1. Ineffective & unsafe treatment

2. Exacerbation or prolongation of illness

3. Distress & harm to patient

4. Increase the cost of treatment

Average number of drugs per encounter is an important index of the scope for educational intervention

in prescribing practices. Our figure of 2.9 drugs per encounter is higher than the internationally

recommended limit of 2.0. In this study three or more drugs were prescribed in 51% of prescriptions

which increases the risk of drug interactions and of the patients not knowing the dosage schedule.

Increasing generic prescribing, which is extremely low and account for only 4%, would rationalize the

use and reduce the cost of drugs.

Appropriate use of antibiotics is necessary to prevent emergence of drug resistant bacteria. Our figureof 12.8% prescriptions having an antibiotic is slightly higher than internationally recommended percent.

Rationalization of the antibiotic prescription will result in lowering treatment costs.

A need arises to reduce injection drug use to prevent healthcare associated infections and other blood

borne pathogens. In the present study injection use is low and represents only 5% of encounters.


24/37

Recommendations

Regularly monitoring of drug use practices in institutions and at household level, as well as

measuring the impact of interventions is an indispensable part of a national RDU strategy;

Development and implementation of the National treatment guidelines and protocols can play avital role for promotion of the rational drug use.

Special attention should be devoted to designing economic strategies to improve drug use,

including policies that reduce incentives for poor drug use, and increase incentives for improved

drug use. Health insurance companies can assist in designing these policies.

Moreover, regulating the patient demand for drugs is an essential strategy. The Insurance

Industry through introduction of the tired Drug Formulary (with differentiated co-payments, co-

insurance) can regulate demand and consequently rationalize expenditures on pharmaceuticals.

Finally, targeted regulatory interventions may be needed to diminish the influence of

promotional activities by the pharmaceutical industry. Controlling the circulation of nonessential

and poor quality drugs in the country may be a difficult but unavoidable step.


25/37

2011

Georgian Insur

I

P

P

Ration

Phar

Expen

Ge

rs Association

FACTORS

FLUENCING

UTPATIENT

PHYSICIANESCRIPTION

ACTICIES IN

GEORGIA

lization of

aceutical

itures in

orgia


26/37

SCOPE OF THE PROBLEM

Health care is under reform in G

cause of the need for changing of h

and policy has been the rapidl

difference between escalating hea

and economic sustainability of

services. The increase of ph

expenditures has outlined the gr

and other health care spending. W

of growth of pharmaceutical expe

well balanced in most Wester

countries it has increased in an e

way in Georgia.

Expenditure on health for theinhabitants in Georgia comprise

Gross Domestic Product (GDP) i

household health expenditure incr

in nominal terms over period of

which amounts to 16.7% annual

year.

Health expenditures have incr

different pace for various services.

care, the average expenditure

population grew by 31%, while f

services the increase was 54%

significant increase is seen for ph

and medical nondurables

amounts to average annual 22.7%

on year10. Per capita sp

pharmaceuticals increased from 1

Gel in current terms (Figure 1).

It is notable that treatment cos

diseases as shown on the Fig

increased mainly on the expe

medicines.

By this time it became obvious t

economic growth and the improv

wealth of the population does n

such an increase in medicines exp

10Household Health expenditure and Utilization

Bank, Curatio International Foundation, 2011

eorgia. Main

ealth system

y increasing

lth care cost

health care

armaceutical

wth of GDP

hile the pace

nditures was

n European

xponentional

4.3 millionof 10% of

n 2010. The

ased by 59%

three years,

growth per

eased at a

For inpatient

er head of

r outpatient

. The most

rmaceuticals

85%, which

growth year

ending for

5 Gel to 194

s of certain

re 2, have

nse of the

he countrys

ment of the

ot allow for

nditure.

Survey, World

Figure 1: Structure of the Per Capita

(2007-2010)

Source: Health expenditure and Utilizatio

Figure 2: Changes in the cost of out

medicines for selected diseases (20

Source: Health expenditure and Utilizatio

Although later fact was rec

government little has taken p

pharmaceutical expenditures

tool, a long-term pharmaceu

helps the explicit decision ma

The current paper attempts tcontributes towards increase

expenditure in Georgia

expenditures can be ration

purpose Three possible co

have been analyzed:

Changes in Consumpt

2007

39

4130

105

In pat ie nt Out pat ie nt Other ser

43%35%

43%

94%

Changes in the cost of outpatie

medicines for selected diseas

Health expenditure

Survey, 2010

atient treatment and

7-2010)

Survey, 2010

gnized by health

lace to rationalize

and to create a

tical policy, which

ing in this field.

understand whatof pharmaceutical

nd how these

alized. For this

ntributing factors

ion Price Index

2010

29

68

34

194

vices Pharmaceuticals

41%

78%

t treatment and

s (2007-2010)


27/37

Characteristics of the phar

market

Characteristics of the presc

practices

CHANGE IN CONSUMPTION PRI

The Health Expenditure a

Survey (HUES) 2010 re

household expenditure in

increased significantly ove

from 2007. The annualised

of expenditure was higher

general inflation. Expe

pharmaceuticals grew at

23.7% year on year (in curr

Figure 3: Consumer price indices and

inflation

Source: State Statistics, 2009

Findings of the HUES are further co

Consumer Price Index published b

general consumer goods and ser

medicines (Figure 3). Geostat dat

price increases for pharmac

outpaced price increases for gener

services in the Georgian econo

October 2007 October 2009.

-5,0

0,0

5,0

10,0

15,0

20,0

25,0

30,0

35,0

ConsumerPriceIndex

Medicines Ove

aceutical

ription

CE INDEX

d Utilisation

vealed that

urrent terms

r three years

growth rate

compared to

nditure on

a pace of

ent terms).

rug price

nfirmed with

Geostat for

ices and for

shows that

euticals far

al goods and

y between

This might be partly due to a

oligopolistic pharmaceutical

long has concerned policy ma

CHARACTERISTICS OF PHA

MARKET

As the main characte

pharmaceutical market, resea

trends of the medicin

market penetratio

Brands (OB) and E

Price Generics (LPG)

Markups on pharmac

Trends in medicine costs

Over the course of one

medicine price change has be

Figure 4: Unit Median Price change

Source: Price, Availability and Affordabilit

Georgia, 2010, WB, Curatio International

11Chanturidze T, Ugulava T, Durn A, Ens

Georgia: Health system review. Health Sy

2009; 11(8):1-116.p.6012

Price, Availability and Affordability of P


rall CPI

-10% -5% 0% 5%

OB

LPG

-6%

n unregulated and

market11

, which

ers.

MACEUTICAL

ristics of the

rchers looked at:

costs

with Original

quivalent Lowest

uticals

year (2009-2010)

n observed12.

(GEL) 2009-2010

y of Medicines in

Foundation

or T and Richardson E.

stems in Transition,

harmaceuticals in

Foundation

0% 15% 20%

16%


28/37

Alongside with OB unit median p

by 6%, LPG median unit price incr

was noted. The price decrease has

the studied basket of medicines e

basket price decrease was observe

medicines, while prices increa

remaining. A same trend has been

the LPG basket, where prices dece

21% of medicines within the baske

Price change appears to be disprop

both, OB and LPG across differe

Georgia which in its term result

financial access options availa

population.

Figure 5: Unit Median Price Change (GEL)

2010

Source: Price, Availability and Affordability of Me

Georgia, 2010, WB, Curatio International Found

Availability of the Original Bran

Equivalent lowest price Generic

Apart from unequal affordability

differences were observed in

availability of medicines. Accordin

research availability has significan

for both OB and LPG (Figure 5), b

different degrees. 33% increase in

LPGs ensures LPG market penetrat

only still being lower than the O

availability country wide accounts f

-20% 0% 20% 40%

Tbilisi

Batumi

Kakheti

Samegrelo

Kvemo Kartli

Imereti

-12%

6%

-4%

-5%

-4%

-8%

-2%

18%

36%

19%

ice decrease

ease by 16%

not affected

qually. In OB

in only 27%

ed for the

observed for

ased for only

.

ortionate for

t regions of

in unequal

ble to the

y Region 2009-

dicines in

tion

ds (OB) and

s (LPG)

vide range

the physical

to the same

tly improved

t again with

availability of

ion by 36.8%

Bs, while OB

or 57%.

Availability of LPGs and OBs di

Figure 6: Percentage Change in Avail

2009-2010



surveyed regions (Figure 6).

being the most underserved

by both LPGs and OBs but at

in 2010, however availability

remains lower of national ave

Thus the market penetration

remains uneven and is mainl

medicines.

Figure 7: Percentage Change in Ava

by regions 2009-2010



Markups

As described above, during

experienced drug unit medi

60% 80%

60%

79%

LPG OB

OB

LPG

Tbilisi

Batumi

Kakheti

Samegrelo

Kvemo Kartli

Imereti

4%

-10%

4%

-14%

1%

8%

5%

4%

-9%

-35%

ffer across

lability of Medicines

y of Medicines in

Foundation

Samegrelo region

has been supplied

different degrees

of both medicines

rage.

with OB and LPGs

flooded with OB

ilability of Medicines

y of Medicines in

Foundation

past year Georgia

n price changes.

25%

33%

159%

47%

LPG OB


29/37

The same study reports that the

not follow the price trend.

Figure 8: Drug Price Markup Change (200

Source: Price, Availability and Affordability of M


Although the markup decreasi

revealed by the study for both, O

is noteworthy to mention that th

LPGs prevails of OB by about 12%

pharmaceutical market (Figure 8).

Figure 9: Comparison of Markups in Georg

European Countries (2009)

Source: Price, Availability and Affordability of Me


The same research compares

Georgia to other European coufindings show that on average mar

to 102% in Georgia, while the lo

been reported is 27% in Hungary (F

High prices of medicines ultimatel

of affordability in the population.

confirmed by the Health Expe

Utilizations Survey (HUES) car

OB

LPG

96

74%

86%

2010 2009

Hungary

Poland

Czech

Greece

Itali

Georgia

27%

32%

35%

46%

49%

markups do

-2010)

dicines in

tion

g trend is

and LPGs, it

markup for

in Georgian

ia to other

dicines in

tion

markups in

ntries. Thekups account

est markup

igure 9).

y raise a risk

his has been

nditure and

ried out in

Georgia. The study res

percentage of consultations

was prescribed but not pur

was too expensive in 2010 i

from 16.4% in 2007.

Based on these findings it isis a room for rationin

expenditures by introductio

promotes cost-containment

control mechanisms, as has

by most of European coun

improves access and affordab

CHARACTERISTICS DRUG U

In order to describe chara

utilization in Georgia and a

impact on the pharmaceutical

paper explores the following

Levels of self treatme

Prescription behavior

Behavior of the phar

Management of

benefits by private ins

Self Treatment

The number of cases of

captured by the HUES was si

2010 (59.3% per 1000 pop

with 2007 (80.3 per 1000

represent only small portion (

The mean amount spent

individual was 20.4 Gel in

significantly higher than the

in 2007 13.4 Gel (Table 1).

13All individuals reporting, Yes on the

any medicine or treatment for this probl

own knowledge and not based on consul

provider in the last 30 days? were includ

%

02%

102%

ults report that

where medicine

hased because it

creased to 21.7%

bvious that therepharmaceutical

of policies that

through price

been experienced

tries, as well as

ility to medicines.

ILIZATION

cteristics of drug

sess its potential

expenditures, the

reas:

t

aceutical market

pharmaceutical

urance industry.

self-treatment13

nificantly lower in

lation) compared

population) and

6%) of population.

y a self-treating

2010, which is

amount observed

uestion Did you take

m based only on your

ing a health care

ed as self-treating.


30/37

Table 14: Mean expenditure per case of se

(current Gel)

Population Groups

2007 HUES

Mean Per

Patient

Urban 14.9

Rural 11.5

Total population 13.4

Source: Health expenditure and Utilization Surve

The largest portion (95%) of the a

on self-treatment is spent on dru

remedies and the rest (5%) on me

and on diagnostic tests when perfo

Prescription behaviors

Inappropriate prescribing reduces

medical care and leads to a waste

Considering the magnitude of re

are wasted on inappropriately

many promising interventions a

inexpensive. This paper looked

evidence in Georgia to uncov

inappropriate prescription practice

Figure 10: Price of Medicine as a fact

Choice

Source: Factors Influencing Prescription Practice

2011, Georgian Insurers Association

Absolute majority (86%) of Georgi

consider drug cost to be highly i

important factor to be well tho

prescription purposes (Figure 10),

2% 12

55%

Not at all Important Not very Important Improtant

lf-treatment

2010 HUES

Mean Per

Patient

21.6

19.4

20.4

, 2010

mount spent

s and herbal

ical supplies

rmed.

he quality of

of resources.

sources that

used drugs,

re relatively

at available

er level of

s.

r of Drug

s in Georgia,

n physicians

portant and

ught-out for

but only few

(7%) physicians take it less

into consideration when pres

Figure 11: Drug Prescription Paterns

Source: Factors Influencing Prescription P

2011, Georgian Insurers Association

It is also noteworthy that

surveyed doctors in Georgia

excellent or satisfactory in

safety and effectiveness and

branded ones. Moreover,

them consider cost of

important factor for prescribi

a reality generic drugs are

physicians do not prescribe

means to curtail expenditure (

Obviously, such behavior isthe lack of knowledge an

and/or negative attitude

prescribing, rather by the inc

the market. Low generic dru

be explained by the combi

factors such as: poorly defi

stewardship and regulato

absence of well formulate

policy, loosely regulated phar

no restrictions for Pharmac

few treatment guidelines an

for utilization, diminishing ro

health human resource

development, including pos

continuous medical

pharmaceutical market

14Factors Influencing Prescription Practi

Georgian Insurers Association

31%

Highly Important

18%

24%

OB LPG Brand

or more seriously

ribing14

.

ractices in Georgia,

ore than half of

ind generic drugs

erms of efficacy,

cheaper to their

ajority (86%) of

edicines as an

g decision, but in

rarely prescribed,

eneric drugs as a

Figure 11).

not influenced byd/or information

towards generic

entives present in

g prescription can

nation of several

ned government

y role, namely

d pharmaceutical

maceutical sector,

utical marketing,

no enforcement

le of the state in

anagement and

t diploma and

ducation and

ecoming major

es in Georgia, 2011,

60%

Generic


31/37

financier of human resource development

activities. Furthermore, in Georgia there are

no financial incentives to motivate physicians to

prescribe generics.

According to the present analysis, the largest

proportion of participants has more than 20

years of practical experience, thus representing

more experienced sample. More than half of

Physicians upgrade their professional education

by attending local or international conferences

and short-term course. It is notable that the

Georgian Government stopped financing of

CME activities for last couple of years. The state

funding is no longer available neither for

participation in local or international

conferences, or for short-term courses in

support of physicians continuous medicaleducation. The professional associations also

fall short to meet members requirements;

therefore these types of educational events at

a lesser degree are financed privately by

doctors and more frequently by Pharmaceutical

companies. Thus the pharmaceutical market

using their financial leverage in support of CME

may have potential influence on physicians

prescription practices.

The study also found that the majority ofphysicians in Georgia believe that a higher price

of medicine imply better patient outcomes. The

perceptions of physicians are that new drugs

are more effective. In case of new drugs,

pharmaceutical market appears to be the most

powerful source of information. About half of

physicians receive information about new drugs

from pharmaceutical sector financed

conferences, sales representatives and drug

marketing materials. These data are consistent

with those from other international studies,

where it has been also shown that

pharmaceutical sales representatives are highly

influential on decisions to prescribe new

drugs1516.

15Prosser H, Almond S, Walley T: Influences of GP's decision to

prescribe new drugs the importance of who says what. Fam

Pract2003, 20:61-68

Even though adverse drug reactions may not

appear very often, they do have a profound

effect on a physician prescribing patterns, so

doctors seek information in order to be

protected and prepared. It is notable, however,

that when they encounter such problems

physicians rarely inform the authorities

accordingly, perhaps because they either do not

know who responsible authority is or do not

want to acknowledge the fact that their

patients had side effects. According to the

finding of the study Georgian physicians mostly

inform pharmaceutical companies (37%) and

share information with colleagues (44%).

On a positive note, the results of the same

study show that one third of physicians use

national and international guidelines to justifytheir drug selection decision. The policy makers

can build on this finding and foster wider use of

guidelines in order to improve treatment

clinical and cost effectiveness.

Behavior of Pharmaceutical Market

Estimation of pharmaceutical market behavior

patterns that influences drug utilization appearsto be difficult due to the limited available

information and research. However, the

anecdotal evidence suggests that pharmacists

are not restricted to change physicians

prescription by substituting prescribed

medicine with alternative, thus promoting

particular brand and/or locally produced

medicines. Such behavior is not regulated by

the legislation, however as it appears to be well

established practice in the market accepted by

the customers, the policymakers can capitalize

on this approach and apply for the

institutionalization of the generic substitution

policy.

16Jones M, Greenfield S, Bradley C: Prescribing new drugs:

qualitative study of influences on consultants and general

practitioners. BMJ 2001, 323:1-7.


32/37

Management of pharmaceutical benefits

by private insurance industry

There has been a striking increase in the

proportion of the population that is covered by

health insurance since 2007. Overall, some 30%

of individuals are covered by health insurance,

with the state financed Medical Insurance

Program (MIP), representing the majority of

coverage, covering some 21% of the population

as a whole and remaining 9% representing

mainly group insurance in 201017

. The MIP did

not provide pharmaceutical benefit (PB) until

summer 2010, though the government may

consider expansion of PB coverage in future.

This paper purposefully avoids analysis of thePB management results for MIP, as the design

and administration of the latter differs from the

private insurance PB management and the data

available for analysis at present is not sufficient

to arrive to sound conclusions. Thus this paper

mainly focuses on analyzing data for private

group and individual insurance.

Table 15: Average pharmaceutical expenditure per

member per year in GEL for group insurance

2007 2008 2009 2010

Reimbursed 31,2 29,6 36,2 39,2

Co-insurance 10,05 11,42 14,4 15,95

Total 41,25 41,02 50,6 55,15

Source: Georgian Insurers Association

The given analysis revealed that total average

expenditure per member per year increases

alongside with increased co-insurance

expenditures (Table 2). However, Insurance

industry manages to maintain lower annualized

growth rate (11%) of pharmaceutical spendingin comparison to overall pharmaceutical

expenditure growth rate (26%).

17Health Expenditure and Utilization Survey, 2010, WB, Curatio

International Foundation

The mechanism applied by insurance industry

for PB management is limited to co-insurance

and negotiated discounts with pharmaceutical

providers only. Indeed later are some of many

other mechanisms that can manage utilization

of medicines, but insufficient to ensure quality

outcomes with lowest cost possible.

The study on pharmaceutical prescription

practices revealed that patients insured

status does not influence prescription decisions.

Forty two percent of surveyed physicians never

take into account the patients insured status

and are free in their drug selection.

Furthermore, medicines are reimbursed on fee

for service basis (FFS) across the board18

and

the market lacks the risk sharing withphysicians, the latter sets perverse incentives

for prescribers to apply cost consciousness in

drug selection.

However, when required, physicians do

consider and base their decisions on the

insurance companys formulary or national

essential drug list (EDL). The industry should

build on this positive experience and use widely

the formularies in the design and management

of the PB.

In summary, though insurance industry

manages pharmaceutical expenditures better,

still has potential for further cost containment.

SUMMARY OF ANALYSIS

This chapter attempts to summarize main

factors influencing the rapid growth of

pharmaceutical expenditures in Georgia.

Absence of price control policy influences levelsof pharmaceutical expenditure. Although

overall price decrease is observed, it effected

mainly OBs, while price increase is detected for

LPGs. Nevertheless, medicine prices in Georgia

are still higher compared to other European

18Georgian Insurers Association , 2011


33/37

countries. The declining trend is

medicine mark-ups as well, but it

significantly higher than in Europe

In the absence of state regulat

exercises free price setting behavio

After all, the price is not the

Efficiency of pharmaceutical sp

depends on appropriate prescripti

pharmaceuticals. Inappropriate

practices are widely spread affectin

cost of treatment. Georgian ph

preference to low generic prescribi

take into account medicine pri

prescribing decisions. Given beh

influenced by the lack of knowl

information and/or negative attit

generic prescribing, rather bintroduced in the market.

Environment appears to be conduc

prescribing as the market is floo

when their generic equivalen

available. Furthermore, the coun

promote utilization of treatment g

ensure compliance, as well as

institutionalize national EDL a

funding of the health hum

development strategy. In the stateniche has been preoccupied by ph

market and used for their marketi

influencing utilization and prescri

in the country.

Furthermore, there is a lack

Incentives to promote cost e

effective treatment. Medicines ar

on fee for service basis across

Furthermore, there are no i

motivate physicians to prescribe ge

Insurance industry succeeded

pharmaceutical expenditure gro

introduction of co-insurance an

price discounts from the ph

market, though underutilizes ot

cost containment strategies that

reported for

still remains

an countries.

ions, market

r.

hole story.

ending also

n and use of

prescribing

g quality and

sicians give

ng and rarely

ces in their

avior is not

edge and/or

ude towards

incentives

ive for brand

ded by OBs,

s are less

try failed to

idelines and

elt short to

d continue

n resource

absence thisarmaceutical

g base, thus

ing patterns

of financial

fficient and

reimbursed

the board.

centives to

nerics.

in lower

th rates by

negotiated

armaceutical

her possible

ould further

decrease pharmaceutical sp

its growth.

RECOMMENDATIONS

In this paper we havapproaches that we feel

sound, broad-based program

use leading to better qua

improved cost effectiveness.

Figure 12: Cost-containment to

pharmaceutical expenditures

Price Volume Ph

Ex

Georgia has to implement dra

pharmaceutical spending, or

growth. The introduction of

medicine policy for health

their attempt to increase va

pharmaceutical spending pro

in some OECD countries.

implemented policies to

uptake through substitution

products with its generic equ

introduced generic pricing st

in some OECD countries

remained underdeveloped

appropriate economic

prescribers, patients and

lacking.

SUPPLY

SIDE

POLICIES

DEMAND

SIDE

POLICIES

nding or contain

recommendedould establish a

for quality drug

lity of care and

ontrol

rmaceutical

enditure

stic policies to cut

t least contain its

coherent generic

service payers in

lue for money in

ed to be effective

They have

promote generic

of brand name

ivalents as well as

rategies. However

generic markets

suggesting that

incentives for

pharmacists are


34/37

Considering the OECD experience Georgia is

recommended to embark on coherent generic

medicine policy, the policy, which contains

supply and demand policy measures (Figure 12).

The following sections presents summary of

policy measures recommended.

SUPPLY SIDE POLICY RECOMMENDATIONS

In order to keep drug price reasonable and

ensure that pharmaceutical expenditures are

either decreased or maintained, different

countries have used direct and indirect price

regulation measures. Price control mechanisms

are various, though this paper recommends

only selected direct and indirect price control

measures for policy makers consideration.

Reference pricing - the purpose of the

reference pricing is to limit the raise in

pharmaceutical expenditure by introduction of

a limit on pharmaceuticals that the payers will

fully reimburse. The reference price is set by

reference to the price of other drugs in a given

category. Different mechanisms are used to

calculate drug reference price: it may be based

on average price of drugs in a given category,

on the price of the cheapest drug, on a price ofthe cheapest generic drug. The patient has to

pay the difference between prescribed drug

price and reference price if the former is priced

higher. As the public financing for the

pharmaceuticals is close to minimum in

Georgia, recommended reference pricing can

be effectively used by the insurance industry as

their cost-containment measure for

pharmaceutical expenditures.

Profit control is an indirect means of controlling

drug prices and aims at ensuring that the firm

does not make excessive profits on the

pharmaceutical products.

Regulation of the distribution channel through

introduction of fixed mark-ups/ margins of

wholesalers and pharmacies is another indirect

Table 16: Summary of Supply Policy

Recommendations

Policy Option Considerations

Direct price control Reference pricing/controls

for reimbursement prices

Distribution controlsalong supply chain

Fixed mark-ups / margins (%)wholesale/distributor, retail

pharmacy

Regressive mark-ups /

margins (motivation to

dispense lower cost

generics)

measure for price control and affects the retail

price of the medicines. Mark-ups that include a

regressive component with or without fixed

fees probably lead to better outcomes that

fixed percentage mark-ups through theirinfluence on financial incentives. However, fixed

fee mark-ups can dramatically increase the

price of otherwise low-cost medicines.

Indirect price control measures are mostly

those that should be endorsed by the state.

Regulation of mark-ups as part of a

comprehensive price regulation strategy

probably will lead to reduced medicine prices.

However, regulation of mark-ups without

regulation of either the manufacturers sellingprice or the retail selling price is unlikely to lead

to reduced medicine prices.

DEMAND SIDE POLICY

RECOMMENDATIONS

Essential drug lists and formularies - Access to

clinically relevant up to date, user specific,

objective and unbiased information is essentialfor appropriate medicine use and basic

requirement for rational prescription practice.

Furthermore, formularies may be used to drive

choice to lower cost drugs by structuring a

sliding scale of co-payments favoring cheaper

products or those for which there is a

preferential agreement with the manufacturer.


35/37

Some financiers may also categorize drugs

according to their essentialness and determine

the level of reimbursement the plan will provide

and the portion that the patient is expected to

pay.

Formularies may also segment drugs intocategories for which a prior authorization is

needed. This is usually done to limit the use of a

high cost drug or one that has potential for

inappropriate use (sometimes called off-label

as it involves using a product to treat conditions

other than those for which its license was

granted). In this circumstance a health care

provider would have to seek permission to

prescribe the product or the pharmacist would

have to obtain permission prior to dispensing it.

Generic Substitution - Generic medicines play a

key role in ensuring the affordability and

sustainability of healthcare systems.

Encouraging competition in the pharmaceutical

market through increasing the use of generic

medicines both promotes cost containment and

stimulates the innovation needed to provide

added value products.

The generic medicines industrys major

contribution to healthcare involves theprovision of high quality, cost-effective

treatment for many of todays most common

chronic illnesses and conditions, such as cancer,

diabetes, depression and high blood pressure.

Providing sustainable treatment for these

illnesses, which are particularly prevalent in

older patients, will become increasingly difficult

as Georgias population ages. In fact, the rapidly

ageing population, the increase in the

prevalence of certain diseases and the rise in

prices for original brands are creating a critical

need for higher volumes of more affordablegeneric medicines.

Introduction of generic substitution will enable

pharmacists to fulfill a prescription for a

branded medicine by dispensing an equivalent

generic medicine. Provision will be made to

allow the prescriber to opt out of substitution

where, in his clinical judgment, it is appropriate

for the patient to receive a specific branded

medicine. In these circumstances, the named

brand must be dispensed. Provision may also be

made to exclude certain categories of

medicines for clinical reasons in the interests of

patient safety.

Influencing Prescription Decisions

Prescription decisions can be influenced

through introduction, training and monitoring

of adherence with the clinical guidelines,

application of different incentive methodologies

designed specifically for prescribers and

patients.

Guidelines are consensus statements developedto assist clinicians in making decisions about

treatment for specific conditions. They are

systematically developed on the basis of

evidence and aim to promote effectiveness and

efficiency of healthcare delivery. To promote

the development and use of guidelines, a

designated body should exist in the country and

be charged with the function of monitoring the

implementation of such guidelines.

Incentive structures relate primarily to targetingthe prescribing behavior of physicians, the

dispensing patterns of pharmacists and

consumer behavior. Physicians responsible for

generating demand for medicines through

prescribing may respond positively to the entry

of generic drugs, but they are not always

sensitive to price. As a result, influencing the

way they prescribe can significantly influence

overall generic prescribing, and can be achieved

by providing them with financial or/and non-

financial incentives.

Physicians have been provided financial

incentives to prescribe cheaper alternatives in

different ways: they may receive per capita

funding for their patients and be allowed to

keep savings achieved through economic

prescribing, as it was a case for some physician

groups in United States or GP fund holders in


36/37

UK. They may be financially rewarded by extra

payments if they reach targets of generic

prescribing, as defined by Pay for Performance

(P4P) schemes.

Financial incentives include prescribing budgets

and provide an explicit incentive to contain

costs, which, in turn, encourages generic

prescribing. The incentives in this case may be

structured to reward physicians who under

spend, or penalize those who overspend, or

both. The international experience suggests

that unless budgets are fixed and linked to clear

and enforceable rules, they are unlikely to

work.

Non-financial incentives affecting physician

prescribing include promotion of genericprescribing, prescription monitoring, audit, and

the use of clinical guidance and IT to influence

prescribing decisions. It is unclear what effect

nonfinancial incentives and measures have in

practice, but it is thought that unless they are

vigorously implemented and monitored, their

effectiveness is likely to be poor19

.

In order to Influence the demand from patients

effective incentives should be introduced.

Incentives for patients depend on out of pocketpayments. The way user charges are designed is

likely to influence the generic take-up when

patients have a choice. Patients have a financial

interest to choose cheaper drugs when the co-

payment is a co-insurance rate (expressed as a

percentage of price), when fixed co-payments

are lower for generic drugs (tired co-

payments). Some countries have supplemented

existing incentives with higher co-insurance rate

for brand named medicines for which cheaper

generic substitutions are available20

.

19Choutet P, Crochet B, et al. The effect of RMO/medical

guidelines based on a critical assessment of antibiotic drug

prescription. Mdecine et maladies infectieuses

2000;30(3)Supplment:185s192s20

Value for money in health spending, OECD Health Policy

Studies, 2010.

Strict Control - Policymakers can improve

health care quality and reduce its costs by

restricting inappropriate drug industry

marketing tactics that undermine the objectivity

of doctors, hospitals and other health care

providers.

Evidence suggests that direct-to-consumer

advertising of prescription drugs increases

pharmaceutical sales and both helps to avert

underuse of medicines and leads to potential

overuse21.

Table 4: Summary of Demand Side Policy

Recommendations

Policy Option Considerations

Defining the market:

listing systems and

formularies

Positive lists for

reimbursements, essential

drug lists

Generic prescribing and

substitution policies

Influencing the

prescribing behavior

Guidelines, protocols

Financial and non-financial

Incentives

Auditing and benchmarking

Influencing the

demand of patients

e.g. cost-sharing,co-payment levels

can be defined

Proportionality to the final

price

Fixed charge perprescription

Annual deductible amount

Strict Control Drug promotion, marketing,

education, sponsorship gifts

to doctors.

Intense marketing inc

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