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Sun 1 Apr 2007 02:14 PM

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Pharmyard rivalry

With branded drug costs soaring, prudent prescribing could mean better patient care.

For most primary care physicians, the act of signing off a script marks the end of a consultation. Once the boxes of diagnosis and treatment have been ticked, they’'ve filled their remit and the details of dispensing can be left to the pharmacist. But when was the last time doctors asked whether a patient could afford the medication selected for them?

Physicians are not often required to play the role of financial advisor to their patients. Courtesy of insurance coverage, or through a patient's private means, the question ‘Can you pay for your medication?' is something doctors rarely need to ask. However, with pharmaceutical costs growing faster than any other slice of the healthcare pie, the issue of prescription drugs, and who has the money to pay for them, is creeping up the care agenda. With compulsory private healthcare on the cards in Saudi Arabia and the UAE, regional physicians can expect to come under increasing pressure from insurers to cut care costs. Abu Dhabi's largest insurance firm, Daman, is leading the way with an annual pharmaceutical cap for patients on its lowest-premium plan, alongside hefty co-payments for those choosing pricey brand-name drugs. Faced with these cost conundrums, physicians must take steps to balance price with clinical effectiveness to ensure patients get the medications they need. One means of ethically tightening the purse strings is through more prudent prescribing; and that means generics.

According to Dubai-based generics firm Medysinal, the net worth of the UAE pharmaceutical market will top AED 4 billion this year. Approximately 85.5% of that sum will come from prescription spending, but only 5% of those scripts will be for a generic drug. When compared to America's US $270 billion pharmaceutical market, where in 2006, 63% of all dispensed prescriptions were for generic medications, industry experts are asking why regional physicians are slow to cash in on the trend.

One reason, according to Dr Sherif Yehia, regional manager at Medysinal, is because they aren't aware of it. "Generic manufacturers are pushed out by multinationals," he explains. "75% of FDA-approved drugs have a generic alternative that is up to 90% cheaper than the brand original, but physicians are creatures of habit. Our biggest challenge is to change the prescribing obsession with certain brand products."

But pitching against the might of big brand pharmaceutical firms is beyond the reach of most generic manufacturers, says Tahir Mustafa, marketing manager for Dubai-based firm GlobalPharma. "Multinational (pharmaceutical) firms have the edge because they can afford to pay more into marketing activities, for a longer, broader reach," he says. "They have an ongoing income from a broad product portfolio. Generics are our core business, so our margins are always tighter."

While most physicians would argue that the pharma-branded pens and post-it notes that clutter their office are little more than a nuisance, there is evidence to show that perks dispensed by pharmaceutical sales representatives do nudge prescribing habits. A British research group found that doctors who have frequent contact with drug representatives are more willing to prescribe new drugs, do not like ending consultations with advice only and are more likely to agree to prescribe a drug that is not clinically indicated. In short, gifts entail obligation and physicians are exchanging their principles for pens. Doctors settle with ‘favourite' brand medications, says Yehia, and are resistant to alternative medicines with the same benefits but a cheaper price tag. "If physicians have one way of thinking, it is hard to convince them to choose another drug," he explains. So how do these prescribing prejudices impact on patients?

According to Dr Abdul Razzaq Yousef, chief executive officer at Julphar, the UAE's largest generic company, by creating drug costs which patients can't meet. "The labouring segment of the UAE - more than 30% of the population - cannot afford to spend money on medicine," he says. "For patients with chronic conditions, over a year or more, the costs really mount up."

And these money worries can significantly affect patient compliance. In one US study of 600 older patients with chronic diseases, each respondent admitted underusing their medication during the previous year because they could not afford it. Two thirds of respondents never told their doctor, while 60% thought there was nothing their doctor could do to help manage their medication costs. Promoting conversation about your patient's financial and insurance status could be one way to help both the prices and the medicine go down.

Patient education

Prescribing routines may be one hurdle in the path of increased generic use, but patient ignorance is another major block, says Dr B.R. Shetty, CEO of generic manufacturer Neopharm. "Patients are not able to differentiate generic products from their innovator counterparts; they perceive the lower price as being a less effective product," he says.

Patients who have been prescribed the same brand for some time are also suspicious of switching to another product, says Yehia. "If a patient has been taking a specific product for some time, for a chronic condition, he or she will be very resistant to another brand," he explains. "There are examples of companies changing something as simple as the colour of a drug pack, yet the patient panics that the drug will be less effective."

Physicians are in the driving seat when it comes to tackling this mindset, Yehia adds. "That is the role of the doctor. He or she can positively influence patients that cannot afford brand versions of medications." Shetty also predicts the rise of private insurance will help drive patient uptake. "Private healthcare business is pro-generic," he states. "The increasing expenses of healthcare will trigger the demand for quality generics."

Certainly, overseas experience has shown patients become savvier with their healthcare dollars once insurance firms enter the picture. Exposing patients to the difference in price between brand and generic pharmaceuticals via co-payment schemes can provide a sizeable financial incentive for making the change. A client survey by Medco, one of the largest US care plans, revealed that increasing the co-payment fee from $5 to $25 or more for a brand medication, where a generic alternative was available, led to a 25% jump in the number of prescriptions filled as a generic. Financial penalties also increase the likelihood of patients actively requesting a generic from their physician, a move Mustafa describes as "vital" in reigning in prescription costs. "As patients begin to ask for generics, we will see a big shift in script data," he adds.

The generic revolution

While patients can request a generic alternative, ultimately physicians sign scripts and pharmaceutical firms are not losing sight of that. "In the drug industry, the patient is not the target; the doctor and pharmacist are," Yousef admits. "The focus is on the clinical process - essentially, the prescribing."

For many doctors, inundated with branded gifts and sales visits, generics are rarely top of their mind. The challenge of staying abreast of generic drugs, as well as remembering the names of the medication, poses a serious snag. "Doctors can remember, probably a maximum of 70 products," says Yousef. "The more medications in the market, the harder it is to get them to remember your brand."

Now, generic firms are fighting back, using the same marketing ploys as their big brand rivals. Hoping to boost its market share, Julphar regularly holds Continuing Medical Education (CME) events for target physicians, in association with bodies such as the Ministry of Health or Harvard Medical International. "We aim to attract key opinion leaders so they are assured of our prescriptions," Yousef explains. "We hope other doctors will follow their example."

Firms Neopharma, GlobalPharma and Medysinal all have teams of sales representatives who are tasked with reminding physicians about the alternatives to brand drugs.

"Face-to-face calls, presentations and interviews have the most positive impact on our relationships with doctors and pharmacists," explains Yehia. "But we also run direct mail campaigns for doctors and pharmacists and an element of our budget is set aside to sponsor conference attendance."

You should also expect to see more generics battling for space in your sample closet, Yousef adds. "Middle East countries allow the distribution of free medical samples to doctors and it is the most effective means of showing the quality of the product."

To date, the sample closet has traditionally been the turf of the newest, most expensive medications. As a result, when physicians dole out ‘starter packs' of brand medication to uninsured or poorer patients, they can unwittingly be prescribing a pricier product when an older, cheaper and effective generic alternative is available.

And, since studies show that patients are most likely to stick with the drug they are first prescribed, resigning their patient to climbing care costs. As the American Medical Association states, "One of the primary ways physicians can practice cost-effective prescribing is by offering patients a generic medicine when one is available."

Getting generics into the sample closet is particularly important in the UAE, says Yousef, as overseas doctors may not be fully aware of the local pharmacy laws. "In the US and Europe, pharmacists can exchange a brand drug for a generic if there is one available," he explains. "In the UAE, it must be specifically prescribed by the doctor. Pharmacists do not have the same freedom."

Prescription for change

In the field of healthcare, where the US and Europe go, the Middle East traditionally follows. GlobalPharma's Mustafa is confident that current international changes will see this trend translate to increased generic drug use. "The generic industry worldwide is growing, which is affecting our industry - there is more acceptance for our products," he says. "There is a local industry coming up. In Saudi, Kuwait and so on, there is support from the government for our industry, because they have a large stake in healthcare costs through public hospitals."

The UAE government is also playing its part in easing the path for generics. Following the lead of the US and Europe, pharmaceutical firms can now apply to register a generic one year before the brand drug loses its patent, speeding up the bench to bedside process and helping to lower costs. Yousef describes this support as "very necessary" in widening the appeal of the generic market. "If the Ministry (of Health) could use the media to explain that, by registering these generic products, that they have guaranteed their efficacy, it would go a long way towards promoting their use," he says.

But the major drive for change must come from the consulting room, Shetty states. "For a doctor, the end point for good treatment is product efficacy. As long as the doctor sees successful therapy outcomes, branded generics should be preferred."

So how can physicians stay ahead of the game on treatment costs? In several ways, says Yehia, starting with reconsidering your "favourite" drug lists. Is the branded drug really the only option in terms of clinical effectiveness, or would your patient benefit from a less expensive drug from the same class? "Think outside the box," Yehia urges. "The generic alternative could be as effective but a cheaper option."

Physicians should also learn the prices of their top 20 prescribed medications. The costs may be surprisingly higher than you thought - could an older, cheaper drug be substituted instead? "If they (the patient) are not insured, it can make a big difference," Yehia says.

Lastly, if there is a generic available that is clinically appropriate, prescribing that, rather than the newest product stocked in your sample closet could save your patients a substantial amount of money.

"Gulf countries insist the first generic drugs should be at least 25% cheaper than the original," Yousef explains. This means prescribing Fluoxetine 10 mg at an estimated $0.46 per capsule rather than Prozac at an estimated $3.40 per capsule would save an uninsured patient more than $1,000 over a year. "In the Gulf countries, there is no clear demarcation of patent expiry dates," Julphar's Yousef explains. "They depend on the US or European patent expiry dates." To keep ahead of new generics due to hit the market, bookmark


Think generic

Physicians should be clinicians first and businessmen second. In a changing healthcare market, however, interaction must go beyond the tasks of diagnosing and treating. Asking about your patient's financial and insurance status and, where possible, prescribing accordingly, should become a standard part of your dialogue. "We want the chronic patient to see, over a period of time, a cost difference," says Yousef. May the best drug win.

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