Unified Prescription Forms : Who Benefits

“The law will make a huge difference for the state, because people will start moving from brand name to generic drugs,” Health Minister Abu Faour told The Daily Star.

After a decade long effort, unified prescription forms will finally be circulated as of early March. Policymakers and industry stakeholders say the adoption of unified prescription forms will expand the market share of generic drugs in Lebanon, saving money for both patients and the government. They also expect transparency and tracking of drug flows to improve.

“The law will make a huge difference for the state, because people will start moving from brand name to generic drugs,” Health Minister Abu Faour told The Daily Star.

He said generic drugs only comprised 13 percent of the pharmaceutical market in Lebanon, whereas in Europe and the U.S., generic use ranges from 80-95 percent.

Abu Faour said that when the law was first passed by Parliament in 2011, it was subsequently stalled due to commercial interests between pharmaceutical firms and doctors.

He elaborated by saying that “some doctors are only prescribing drugs that are produced or marketed by certain companies.”

Prior to the adoption of the law, the Order of Physicians said it would not proceed with printing the forms until the amendment of Article 42 of the bylaws of the National Social Security Fund.

The bylaws required pharmacists to sell to patients only the medication written on the prescription form. They could not sell generic drugs or comparable substitutes, even at the patient’s request.

The bylaws are now being changed to allow patients to purchase generic medications, and on Feb. 19 the Order of Physicians agreed to begin printing the unified prescription forms starting in March.

The forms will be purchased by doctors throughout the country, and will include three copies: one for physicians, one for the patient and one for the pharmacist.

The doctor’s name, contact information and registration number with the Order of Physicians will be printed on the forms. Abu Faour said use of the forms would help fight corruption.

Head of the Order of Physicians Antoine Boustani expressed support for the unified prescription forms, saying amending the NSSF bylaws was necessary prior to adopting the forms as it would ensure that patients are reimbursed for generic medications they choose to substitute for name brands.

“It’s important that patients would have that kind of freedom without losing the advantage of a NSSF coverage, and so that the action mechanism would work,” Boustani said.

A crucial element of the forms is the option for a doctor to prohibit substitution. Doctors can prevent their patients’ preference to switching to a generic or cheaper name brand drug by indicating on the form that only the drug prescribed should be purchased.

When the doctor does not stop substitution, and the patient chooses a different drug than the one prescribed, pharmacists must document that patient’s acceptance of the substituted drug at the time of purchase.

According to Boustani, the “no substitution” option is for the benefit of the patient.

“It is very necessary for doctors to make sure the patients take the right medication, which is vital in some cases and can’t be replaced by generic medicines,” he said.

Rabih Hassouna, president of Lebanon’s Order of Pharmacists, saw the implementation of unified prescription forms as a positive move, as it will enhance the monitoring of medications sold in the country, and enable pharmacists to practice their profession beyond the role of commercial sales.

“We supported the implementation from the beginning because we believe it is the first step in organizing the medical field and the pharmaceutical market in Lebanon to make it more transparent,” he said, adding that the forms give “freedom to the pharmacist to exchange the product based on his competency and training.”

He explained that generic drugs in Lebanon hold such a small share of the market due to public perception that they are inferior to name brand drugs, and pointed to the marketing efforts of pharmaceutical companies as a key contributor to that notion.

“There is a big influence by pharmaceutical companies, either the brand name companies or generic [drug manufacturers], let’s be fair and not only attack the brand name companies,” Hassouna said.

A 2009 WHO report on transparency in Lebanon’s pharmaceutical sector attributed the low use of generics in Lebanon to pharmaceutical companies’ heavy influence on doctors, which “has created trade name affinity and loyalty.”

Mohammad Jawad Khalifeh, health minister from 2005-11, agreed that the general public has a misconception about the quality of generic drugs, saying that during his tenure as minister, he had sought to counter public opinion with awareness campaigns.

He explained that the majority of generics are brand name drugs beyond the patent expiration date.

“They are not changing anything [about the drug], it is just that the patent expired,” he said.

According to the WHO, a generic drug is “a pharmaceutical product, usually intended to be interchangeable with an innovator product, that is manufactured without a license from the innovator company and marketed after the expiry date of the patent or other exclusive rights.”

Khalifeh was one of the main advocates of unified prescription forms, spearheading the effort to adopt the law during his time as minister, as part of a larger campaign for health care reform in Lebanon. He aimed to reduce the high cost of pharmaceuticals for the benefit of the public as well as the state.

“The NSSF is suffering from great losses from paying for branded medications,” he said.

As the insurance scheme that covers over a million Lebanese working in the public and private sectors, the NSSF functions on employer contributions and, in general, reimburses patients for 80 percent of drug costs.

The Daily Star reported in 2012 that the NSSF had accumulated a deficit of approximately LL431 billion, as of late 2011.

Khalifeh stressed the need for electronic record keeping in tandem with the use of unified prescription forms, so that auditors of pharmacies could obtain complete data that would enable the government to monitor and expose cases of smuggling.

A doctor who spoke to The Daily Star on the condition of anonymity expressed concern that doctors may abuse the power given for the “no substitution option” on the form.

“If the doctor stops prescribing brand name drugs, it may affect the incentives he was receiving from the pharmaceutical company, because that doctor’s sales of the drug would be less,” she said.

She added that patients suffering from chronic diseases would benefit most from having the power to choose generic drugs because they “will need drugs for the rest of their lives. If they are the patient of a doctor who only prescribes brand names, and not generics, they will spend a lot of money on their medications. Those from a poor background will end up paying more. It’s a social justice issue.”

Rates of chronic diseases are increasing in Lebanon, as life spans lengthen and increasing numbers of Lebanese suffer from conditions such as diabetes, heart disease and cancer.

Armand Phares, president of the Lebanese Pharmaceutical Importers Association, reacted positively to the adoption of unified prescription forms, speculating that they would improve ethical decision-making among pharmaceutical sales representatives, doctors and pharmacists.

“By opening the door to substitution under very strict conditions, the effect of the unified medical prescription paves the way to enlarging the market share of comparable [or] lower priced drugs versus their originators or other generics,” Phares said.

He added that setting a comparable list of generic drugs is difficult, as those involved must ensure that the generic has the same active ingredient and the same dosage as the name brand drug. Also, attention must be paid to the inactive ingredients that were part of the manufacturing process, as they can affect drug safety.

Labor Minister Sejaan Azzi said on Feb. 20 that NSSF coverage of generics only extends to those drugs on a World Health Organization-approved list of substitutes, published by the Health Ministry.

Moreover, the patient must give his consent before a prescribed drug can be substituted.

Reference: The Daily Star