1Pharmaceutical Association of Fthiotida Prefecture, Lamia, Greece
2Technological Educational Institute of Western Greece, Faculty of Nursing, Patra, Greece
3Open University of Cyprus, Latsia, Cyprus
4National School of Public Health, Open University of Cyprus, Latsia, Cyprus
Background Measures taken over the past four years in Greece to reduce pharmaceutical expenditure have led to significant price reductions for medicines, but have also changed patient cost-sharing rates for prescription drugs. This study attempts to capture the resulting increase in patients’ out-of-pocket (OOP) expenses for prescription drugs during the 2011-2014 period.
Methods The authors conducted a retrospective review of financial data derived from 39 883 prescriptions, dispensed at three randomly chosen pharmacies located in Lamia, central Greece.
Results The study recorded an average contribution rate per prescription as follows: 11.28% for 2011 (95% CI: 10.76-11.80), 14.10% for 2012, 19.97% for 2013, and 29.08% for 2014. Correspondingly, the mean patient charge per prescription for 2011 was €6.58 (95% CI: 6.22-6.94), €8.28 for 2012, €8.35 for 2013, and €10.87 for 2014. During the 2011-2014 period, mean percentage rate of patient contribution increased by 157.75%, while average patient charge per prescription in current prices increased by 65.22%. The use of a newly introduced internal reference price (IRP) system increased the level of prescription charge at a rate of 2.41% for 2012 (100% surcharge on patients), 26.24% for 2013 (49.95% on patients and 50.04% on the appropriate health insurance funds), and 47.72% for 2014 (85.06% on patients and 14.94% on funds).
Conclusion Increased cost-sharing rates for prescription drugs can reduce public pharmaceutical expenditure, but international experience shows that rising OOP expenses can compromise patients’ ability to pay, particularly when it comes to chronic diseases and vulnerable populations. Various suggestions could be effective in refining the costsharing approach by giving greater consideration to chronic patients, and to the poor and elderly.
OECD/European Union. Pharmaceutical expenditure. In: Health at a Glance: Europe 2014. OECD publishing; 2014.
The Pharmaceutical Market in Greece. Annual Report 2012. Athens: Institute of Economics and Industrial Research, Centre of Health Economics; 2013.
Ministerial Judgment Φ.42000/n.12485/1481. Greek Government Gazette: 1814/Β/8.6.2012
Ministerial Judgment ΔΥΓ3(α) /n. 4146. Greek Government Gazette: 43/Β/15.1.2013
Siskou CO, Kaitelidou CD, Litsa SP, et al. Investigating the economic impacts of new public pharmaceutical policies in Greece: focusing on price reductions and cost-sharing rates. Value Health Reg Issues. 2014;4:107-114.
Ministerial Judgment n. 82961. Greek Government Gazette: 2219/Β/9.9.2013
Ministerial Judgment οικ.113429. Greek Government Gazette: 3117/Β/9.12.2013
Souliotis K, Papageorgiou M, Politi A, Frangos N, Tountas Y. Estimating the fiscal effects of public pharmaceutical expenditure reduction in Greece. Front Public Health. 2015;3:203. doi:10.3389/fpubh.2015.00203
Law Ν. 4093. Greek Government Gazette: 222/Α/12.11.2012
Ministerial Judgment n.82961. Greek Government Gazette: 2219/Β/9.9.2013
Vogler S, Zimmermann N, Leopold C, de Joncheere K. Pharmaceutical policies in European countries in response to the global financial crisis. South Med Rev. 2011;4(2):69-79. doi:10.5655/smr.v4i2.1004
Cuttler D, Everett W. Thinking outside the pillbox – medication adherence as a priority for health care reform. N Engl J Med. 2010;362(17):1553-1555. doi:10.1056/nejmp1002305.
Sinnott SJ, Buckley C, O'Riordan D, Bradley C, Whelton H. The effect of copayments for prescriptions on adherence to prescription medicines in publicly insured populations; a systematic review and meta-analysis. PLoS One. 2013;8(5):e64914. doi:10.1371/journal.pone.0064914
Luiza VL, Chaves LA, Silva RM, et al. Pharmaceutical policies: effects of cap and co-payment on rational use of medicines. Cochrane Database Syst Rev. 2015;5:CD007017. doi:10.1002/14651858.cd007017.pub2
Mann BS, Barnieh L, Tang K, et al. Association between drug insurance cost-sharing strategies and outcomes in patients with chronic diseases: a systematic review. PLoS One. 2014;9(3):e89168. doi:10.1371/journal.pone.0089168
Tablyn R, Laprise R, Hanley JA, et al. Adverse events associated with prescription drug cost-sharing among poor and elderly persons. JAMA. 2001;285(4):421-429. doi:10.1001/jama.285.4.421
Page RL, Barton P, Nair K. Effect of cost-sharing for prescription medications on health outcomes in older adults: a critical review of the literature and potential implications for managed care. Consult Pharm. 2008;23(1):44-54. doi:10.4140/tcp.n.2008.44
Terraneo M, Sarti S, Tognetti Bordogna M. Social inequalities and pharmaceutical cost-sharing in Italian regions. Int J Health Serv. 2014;44(4):761-785. doi:10.2190/hs.44.4.e
Puig-Junoy J, Rodríguez-Feijoó S, Lopez-Valcarcel BG. Paying for formerly free medicines in Spain after 1 year of co-payment: changes in the number of dispensed prescriptions. Appl Health Econ Health Policy. 2014;12(3):279-287. doi:10.1007/s40258-014-0097-6
Lesén E, Andersson Sundell K, Carlsten A, Mårdby AC, Jönsson AK. Is the level of patient co-payment for medicines associated with refill adherence in Sweden? Eur J Public Health. 2014;24(1):85-90. doi:10.1093/eurpub/ckt062
Hynd A, Roughead EE, Preen DB, Glover J, Bulsara M, Semmens J. The impact of co-payment increases on dispensings of government-subsidised medicines in Australia. Pharmacoepidemiol Drug Saf. 2008;17(11):1091-1099. doi:10.1002/pds.1670
Tsiligianni I, Papadokostakis P, Prokopiadou D, Stefanaki I, Tsakountakis N, Lionis C. Impact of the financial crisis on adherence to treatment of a rural population in Crete, Greece. Qual Prim Care. 2015;22(5):38-44.
Skroumpelos A, Pavi E, Mylona K, Kyriopoulos J. The impact of economic crisis on chronic patients’ self-rated health, health expenditures and health services utilization. Diseases. 2014;2:93-105. doi:10.3390/diseases2020093
Pappa E, Kontodimopoulos N, Papadopoulos AA, Tountas Y, Niakas D. Prescribed drug utilization and polypharmacy in a general population in Greece: association with socio-demographic, health needs, health services utilization and lifestyle factors. Eur J Clin Pharm. 2011;67(2):185-193. doi:10.1007/s00228-010-0940-0
Gatwood J, Gibson TB, Chernew ME, Farr AM, Vogtmann E, Fendrick AM. Price elasticity and medication use: cost-sharing across multiple clinical conditions. J Manag Care Spec Pharm. 2014;20(11):1102-1107. doi:10.18553/jmcp.2014.20.11.1102
Hossein Z, Gerard A. Trends in cost-sharing among selected high income countries--2000-2010. Health Policy. 2013;112(1-2):35-44. doi:10.1016/j.healthpol.2013.05.020
Cohn J. An overdose of out-of-pocket expenses. Milbank Q. 2014;92(3):418-421.
Riggs KR, Ubel PA. Overcoming barriers to discussing out-of-pocket costs with patients. JAMA Intern Med. 2014;174(6):849-850. doi:10.1001/jamainternmed.2014.853
Petrou P, Vandoros S. Cyprus in crisis: recent changes in the pharmaceutical market and options for further reforms without sacrificing access to or quality of treatment. Health Policy. 2015;119(5):563-568. doi:10.1016/j.healthpol.2015.03.004
Petrou P, Talias MA. Tendering for pharmaceuticals as a reimbursement tool in the Cyprus public health sector. Health Policy Technol. 2014;3(3):167-175. doi:10.1016/j.hlpt.2014.04.003
Wouters OJ, Kanavos PG. Transitioning to a national health system in Cyprus: a stakeholder analysis of pharmaceutical policy reform. Bull World Health Organ. 2015;93(9):606-613. doi:10.2471/blt.14.148742
Frouzi E, Chatzea VE, Sifaki Pistola D, Saridi M, Rekleiti M, Souliotis K. Knowledge and attitudes of Greek physicians towards generic prescribing after the economic crisis. Int J Pharm Sci Res. 2013;4(10):125-133.
The Organization for Economic Co-operation and Development (OECD). Pharmaceutical expenditure. in Health at a Glance 2011: OECD Indicators. OECD Publishing; 2011. http://dx.doi.org/10.1787/health_glance-2011-en. Accessed March 8, 2016.
Sinnott SJ, Normand C, Byrne S, Woods N, Whelton H. Copayments for prescription medicines on a public health insurance scheme in Ireland. Pharmacoepidemiol Drug Saf. 2015. doi:10.1002/pds.3917
Spillane S, Usher C, Bennett K, Adams R, Barry M. Introduction of generic substitution and reference pricing in Ireland: early effects on state pharmaceutical expenditure and generic penetration, and associated success factors. J Pharm Policy Pract. 2015;8(suppl 1):O10.
Lambrelli D, O'Donnell O. The impotence of price controls: failed attempts to constrain pharmaceutical expenditures in Greece. Health Policy. 2011;101(2):162-171. doi:10.1016/j.healthpol.2010.08.023
Presidential Decree n. 121. Greek Government Gazette: 183/Α/3.9.2008
Law Ν. 3892. Greek Government Gazette: 189/Α/4.11.2010
Carone G, Schwierz C, Xavier A. Cost-containment policies in public pharmaceutical spending in the EU. Brussels: European Commission Directorate-General for Economic and Financial Affairs Publications; 2012.
Soumerai SB. Benefits and risks of increasing restrictions on access to costly drugs in Medicaid. Health Aff (Millwood). 2004;23(1):135-146. doi:10.1377/hlthaff.23.1.135
Tordrup D, Angelis A, Kanavos P. Preferences on policy options for ensuring the financial sustainability of health care services in the future: results of a stakeholder survey. Appl Health Econ Health Policy. 2013;11(6):639-652. doi:10.1007/s40258-013-0056-7