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Hungary pains

Reforms to push generic prescribing have made life harder for doctors and pharmacists

Illustration of doctors and nurse standing infront of Hungary flag With Hungary's accession to the EU in 2004, legislation had to be harmonised with the EU regulations and a transparent and predictable system for the distribution and pricing of pharmaceuticals was required.

The government had to cut costs, and the main objectives of reforms enacted in 2007 were to curb excessive medicine consumption and promote generics.

Employees in Hungary contribute six per cent of their pay to a social insurance fund, and employers contribute five per cent of payroll. Those with no earned income, such as the unemployed and pensioners, have their contributions met by the government.

There is a charge for prescriptions and for some services such as dental care. Rules on medicine subsidies were tightened and co-payments were introduced – but were abolished one year later after a referendum.

Reference pricing was applied, with medicines classified into regularly updated groups. In each group a favourably-priced product is selected and the extent of financing for that group is based on the gross consumer price of that medicine. Doctors and pharmacists must inform patients of the differences between the fees payable for equivalent medicines – if the patient chooses the more expensive one, they pay the difference.

Savings achieved by promoting generics were to ensure that healthcare standards in Hungary did not fall behind the rest of Europe, but this has not been achieved as yet.

Regulations governing pharmacies were changed. They can now be less than 250m apart and those with higher profit margins have to pay a 'solidarity tax'. Numerous over-the-counter (OTC) medicines were also authorised for sale in supermarkets and petrol stations.

Measuring the impact
We measured the impact of the 2007 reforms on doctors' prescribing, pharmacists' dispensing and patients' consumption habits, focusing on gynaecological medicines. In Hungary, women go to the gynaecologist for  pregnancy advice, contraception, smear tests and all gynaecological problems. The most significant medicines were the reimbursed ones for conditions such as local and systemic medicines for vulvovaginal infections and  menopausal hormone therapy. We also looked at free oral contraceptives.

The groups surveyed were nationally representative in terms of age-group and regional distribution – see table.

Date of survey
Gynaecologists
Pharmacists
Patients (Female)
November 2007
122
123
103
November 2008
155
120
124



Traditionally, doctors are the buyer and the seller, as they offer a specific medicine to the patient. Our survey indicated that gynaecologists feel reforms have eroded their role and detracted from their freedom to make treatment-related decisions. The Pharmaceutical Cost-efficiency Act has shifted the focus to cheaper, generic products.

There has been merging and closure of hospitals resulting in disruption and job change. The impression we got was that the gynaecologists surveyed believe the reforms are ill-considered and have created uncertainty and stress. They feel weighed down by the administrative workload needed to justify cost and the extra paperwork required if they choose a more expensive medicine.

They find it difficult to keep track of medicine price changes and feel that patients are hit hardest by these reforms. One respondent expressed the view that the generic products were less efficacious: "We return to the original medicine anyway, because the generic product doesn't work."

They regard the increased emphasis on price as detracting from the value of their professional work. Most of the gynaecologists are wary of generics that they are not familiar with. They make the diagnosis and they want to choose the best therapy according to their experience, regardless of price.

The efficacy and the safety of the medicines are still the most important factors considered when choosing what to prescribe. All doctors have become more cost-aware.

It is important for pharma companies to emphasise pricing policies, monitor their reference group and, if necessary, decrease the price to save their reimbursement. Reps retain a key role in the dissemination of professional information. The internet, however, has gained ground, with 71 per cent of gynaecologists happy to receive information by email. In addition, 53 per cent visit a specialist website at least once a week. Internet channels enable dissemination of information that can be updated quickly in line with changes in the market. Online networking presents opportunities particularly for improving the image of the industry.

Pharmacists
The number of pharmacies in Hungary is growing, and chains are being established. Competition is leading them to become patient-centred. Price competition, generic substitution and the constantly changing reference medicines have made it essential for reps to visit pharmacies regularly.

Frequent changes to price and subsidies mean that pharmacists can't predict which product they should keep in storage and so are unable to plan and maintain optimum stock levels.

Of those pharmacists surveyed, 62 per cent detected a change in their dispensing habits – mainly a rise in the number of generic substitutions. Many of the pharmacists expressed the view that their work is more difficult, because they have to explain more to the patients, who, in turn, are not always happy to accept generic products.

Half of the pharmacists believe that too much emphasis is placed on dispensing generic products, and the austerity measures imposed on doctors is diverting focus away from the patients and their treatment.

The pharmacists attempt to substitute almost half (47 per cent) of prescription drugs prescribed by doctors – mainly when they don't have adequate stocks of the branded medicine. In almost a fifth of the cases the patients request substitution with a cheaper product in the pharmacy. This figure is rising.

Pharmacists claim that substitutions they initiate are accepted by 25–30 per cent of patients, at most. This means that, in all but 10-15 per cent of cases, the patient leaves the pharmacy with the branded medicine originally prescribed.

Extra services to patients, such as screening, advice and the online ordering and home delivery of medicines are in demand. Pharmacists also direct patients to a doctor, monitor therapy and help them to develop a healthy lifestyle. Supporting these endeavours must constitute an important part of pharmaceutical companies' future marketing strategies.

Female population
The healthcare reforms have not affected the doctor/patient relationship –  despite the fact that 61 per cent of respondents believe that the quality of patient care has deteriorated. In every age-group, most women surveyed (77 per cent) only visit their gynaecologist immediately in the case of a serious complaint.

Some 44 per cent of women surveyed state that TV advertisements do not influence their consumption habits for OTC medicines. A third always seek a doctor's opinion before buying a product they have seen on TV. The proportion of people who, where necessary, try the medicines advertised on TV without any other professional support is 23 per cent. The percentage is similar in the case of newspaper ads.

People regard materials distributed in pharmacies as far more credible, with 67 per cent of respondents saying that if an advert attracted their attention, they would be inclined to try the promoted medicine.

Interest in receiving emails with a healthcare-related content is high (78 per cent), but the number who regularly visit health-related websites is low (at only 30 per cent of respondents). The use of the internet for healthcare-related purposes is lowest among older people.

The number of those who have ordered OTC and/or prescription medicines from legitimate internet sources is negligible (1.6 per cent). A third of the respondents were not even aware of this opportunity and 64 per cent said they have more faith in "traditional dispensaries".

Of the 94 per cent of respondents who maintain a 'home pharmacy', most stockpile three to five medicines – both OTC and prescription – on a regular basis. Those who don't keep a stock of drugs cite the fact that they always visit a doctor if they have a problem.

Half of respondents are not opposed  to buying OTC medicines outside of the pharmacy and a fifth already have. They believe it will lead to more competition and cheaper prices. Those opposed feel that it results in a lack of control over people's medicine consumption.

In our experience, patients identify medicines by the packaging and the manufacturer's name, not by the active ingredient. This is why they often mistrust new medicines. Price changes mean some doctors are constantly changing their patients' medication, thus heightening uncertainty. It is important for patient concordance that all queries are clarified before they leave the surgery.

Our survey indicates that most patients are sceptical about generic substitutions. Some are happy to pay less, but others believe that more expensive means better. Patients who have placed their trust in a given medicine are brand-loyal. Those who refuse substitutions often cite a past negative experience (diminished or altered effect and side-effects) – although the basis for this could be mainly psychological.

If their doctor states that two medicines are equally efficacious and tolerable, then 43 per cent of respondents would choose the lower-priced product. Almost one-third of the women surveyed believe that a cheaper medicine can be just as efficacious as an expensive one. If the cheaper medicine is made by a well-known, trustworthy pharma company, 17 per cent of respondents would have no qualms about taking the cheaper product.

Only eight per cent of participants said they preferred the more expensive product, because they feel that there is a quality-related reason for the price difference. Some 30 per cent of the women would not change their tried and tested medicine under any circumstances. The highest rate of rejection is in the 38–51 age group (49 per cent). The proportion of those who unquestioningly agree to the substitution of their medicine is 13 per cent.

The patient-orientated approach and the growing importance of health education is a positive development that has shifted the patient role towards that of buyer. Forging relationships with pharmacists and developing medical education aimed at the general public are crucial elements in pharma companies' marketing strategies. There are other payers in Hungary, but good marketing strategy still focuses on doctor, pharmacist and patient.

The Author
Barbara Gal-Knippel Pharm D is product manager in gynaecology at Gedeon Richter
To comment on this article, email pme@pmlive.com

21st July 2009

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