Pharmaceutical policies: effects of financial incentives for prescribers

 

Abstract

Background

Pharmaceuticals, while central to medical therapy, pose a significant burden to health care budgets. Therefore regulations to control prescribing costs and improve quality of care are implemented increasingly. These include the use of financial incentives for prescribers, namely increased financial accountability using budgets and performance based payments.

Objectives

To determine the effects on drug use, healthcare utilisation, health outcomes and costs (expenditures) of policies, that intend to affect prescribers by means of financial incentives.

Search methods

We searched the following databases and web sites: Effective Practice and Organisation of Care Group Register (August 2003), Cochrane Central Register of Controlled Trials (October 2003), MEDLINE (October 2005), EMBASE (October 2005), and other databases.

Selection criteria

Policies were defined as laws, rules, financial and administrative orders made by governments, non-government organisations or private insurers. One of the following outcomes had to be reported: drug use, healthcare utilisation, health outcomes, and costs. The study had to be a randomised or non-randomised controlled trial, interrupted time series analysis, repeated measures study or controlled before-after study evaluating financial incentives for prescribers introduced for a jurisdiction or healthcare system.

Data collection and analysis

Two review authors independently extracted data and assessed study limitations.

Main results

Thirteen evaluations of budgetary policies and none of performance based payments met our inclusion criteria. Ten studies evaluated general practice fundholding in the UK, one the Irish Indicative Drug Target Savings Scheme (IDTSS) and two evaluated German drug budgets for physicians in private practice. The interrupted time series analyses had some limitations. All the controlled before-after studies (all from the UK) had serious limitations.

Drug expenditure (per item and per patient) and prescribed drug volume decreased with budgets in all three countries. Evidence indicated increased use of generic drugs in the UK and Ireland, but was inconclusive on the use of new and expensive drugs. We found no clear evidence of increased health care utilisation and no studies reporting effects on health. Administration costs were not reported. No studies on the effects of performance-based payments or other policies met our inclusion criteria.

Authors' conclusions

Based on the evidence in this review from three Western European countries, drug budgets for physicians in private practice can limit drug expenditure by limiting the volume of prescribed drugs, increasing the use of generic drugs or both. Since the majority of studies included were found to have serious limitations, these results should be interpreted with care.

 

Plain language summary

Pharmaceutical policies: effects of financial incentives for prescribers

Drugs make up a major part of the amount of money spent on health care. Today, figures from across the world show that the amount spent on drugs is increasing. Spending more on drugs could mean less money for hospitals, doctors or even schools and other non-health care services. There is, therefore, pressure to control the costs of drugs while maintaining the quality of health care or avoiding the increase in the use of health services.One way for governments, non-government agencies and health insurance companies to try to control drug spending is to influence those who prescribe drugs through financial incentives. This review is about two types of financial incentives that directly affect prescribers: drug budgets and performance based payments (e.g. bonuses or fines to improve prescribing and reduce costs). We included 13 studies from the UK, Ireland and Germany that evaluated budgets, but no studies that evaluated performance based payments.

Budgets are funds that are allocated by payers to a group of or individual physicians, thereby giving them financial responsibility for the management of their own budget. Budgets provide incentives to prescribers to prescribe fewer and less expensive drugs (such as generic drugs). This review found that in these three countries drug spending (per item and per patient) and the volume of drugs prescribed decreased, with more prescribing of generic drugs. There was no clear evidence about the effects of budgets on health care utilization (such as referrals to specialists). The effects on health were not reported in the studies. Overall the evidence for the effects of budgets is weak.

 

摘要

背景

藥物政策:財務誘因對於處方者的影響

當集中藥物治療時，藥物對於健康照護預算造成重大的負擔。因此控制處方成本並促進照護品質的規定逐漸被實行。這些包括利用財務誘因，也就是利用預算及績效為基礎的支付制度來增加財務。

目標

確定藥物使用，健康照護利用，健康結果及成本(費用)的政策效果，期望藉由財務誘因的手段來影響處方者。

搜尋策略

我們檢索以下的資料庫及網站：Effective Practice and Organisation of Care Group Register (2003年8月), Cochrane Central Register of Controlled Trials (2003年10月), MEDLINE (2005年10月), EMBASE (2005年10月)及其他的資料庫。

選擇標準

政策被定義為由各國政府，非政府組織或私人保險所制定的法律，規定，財務及行政命令。研究必須報告下列其中之一的結果：藥物使用，健康照護利用，健康結果及成本。研究必須是隨機的或非隨機的對照試驗，間斷時間序列分析，重複測量研究或前後對照研究，其評估司法或健康照護系統所推行對處方者之財務誘因。

資料收集與分析

兩名回顧作者分別獨立摘錄資料並評估研究限制。

主要結論

13篇研究評估預算政策，且沒有以績效為基礎的支付制度研究符合納入標準。10篇研究評估英國家庭醫師基金(general practice fundholding)，一篇評估愛爾蘭的藥物靶點儲蓄計劃(Drug Target Savings Scheme (IDTSS))，兩篇評估德國私人開業醫師之藥物預算。間斷時間序列分析有一些限制。所有的前後對照研究(皆來自英國)有嚴重的研究限制。在所有三個國家中，藥物費用(每個藥物品項及每名病人)及藥物處方量隨預算減少。證據指出在英國及愛爾蘭會增加一般性藥品的使用，但新藥或昂貴藥品則沒有定論。我們沒有發現明確有關增加健康照護利用的證據，且沒有研究有關健康影響的報告。沒有研究有關以績效為基礎的支付制度或其他政策符合我們的納入標準。

作者結論

依據這篇回顧來自三個西歐國家的證據，對於私人開業醫的藥物預算可以限制藥物費用，藉由限制藥物處方量，增加一般性藥品使用或兩者皆有之。由於蒐集到的多數研究發現有嚴重的限制，這些結果應小心解釋。

翻譯人

本摘要由高雄榮民總醫院金沁琳翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

藥物造成健康照護上主要的金錢花費。如今，透過世界各國的描述顯示藥物的花費日益增加中。花費較多的藥物可以解釋為花費較少在住院上，醫師或甚至學校或其他的非健康照護服務。因此有控制藥物成本的壓力，維持健康照護品質或避免增加健康服務的利用。 各國政府，非政府機構及健康保險公司嘗試控制藥物花費的一種方法便是透過財務誘因影響那些處方者。這篇回顧是有關兩種直接影響處方者的財務誘因：藥物預算及以績效為基礎的支付制度(如獎金或懲罰以改善處方並減少成本。我們蒐集13篇來自英國，愛爾蘭及德國的研究，其評估預算，但沒有研究評估以績效為基礎的支付制度。 預算是經由付費者將資金分配予一個團體或個別醫師，因此賦予他們財務責任以管理他們自身的預算。預算提供誘因使處方者調配較少且較不昂貴的藥物(如一般性藥物)。這篇回顧發現在這三個國家中，藥物花費(每個藥品項目及每名病人)及藥物處方量減少，而一般性藥物的處方則增加。沒有明確的證據有關預算對於健康照護利用的效果(如轉介至專科醫師)．這些研究沒有報告對於健康的影響。整體來說有關預算效果的證據是薄弱的。