Article

The Effect of Biosimilar Prescription Targets for Erythropoiesis-Stimulating Agents on the Prescribing Behavior of Physicians in Germany

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Abstract

Objectives This study aimed to aid decision makers by analyzing the impact of introducing biosimilar prescription targets on physician prescribing behavior in the prescription of biologic erythropoiesis-stimulating agents in Germany. Methods We combined secondary data of regional level biosimilar prescription targets and secondary data of routinely collected claims data of dispensed prescriptions by physicians operating within the statutory health insurance system in ambulatory care across 7 German regions from 2009 to 2015. Two-way fixed-effects regression analysis was used to identify the average treatment effect of introducing biosimilar prescription targets at the physician level. The main outcome of interest was the share of biosimilar prescriptions on all prescriptions within the substance group. We compared 6 regions that introduced biosimilar prescription targets with 1 region without any prescription target policy. Results Introducing biosimilar prescription targets increased the average share of biosimilars between 6 percentage points (P < .05) in Hamburg and up to 20 percentage points (P < .001) in Saxony-Anhalt. Stratification of specialists by prescription volume and adoption status indicated heterogeneous effects. We identified similar but higher effects for high-volume prescribers. Disentangling of effects with regard to the composition of biosimilar share suggested that the increase in biosimilar share was driven by increased biosimilar use accompanied by a nonsignificant decrease in original biologics prescriptions. Conclusions Prescription targets to alter physician prescribing behavior meet their intended goals by increasing biosimilar share. Physicians partly responded to the policy by decreasing overall prescriptions of the target substance. Prescription targets might be a useful tool, but decision makers need to consider all aspects of potential responses.

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Study results documenting substantial cost savings achieved by an outpatient indigent-care pharmacy program through formulary modifications and optimized purchasing practices are presented. Wholesale purchasing data were retrospectively evaluated to compare drug expenditures before and after a large Florida hospital's adoption of a tiered formulary system for three ambulatory care facilities serving mostly uninsured patients. The outcomes assessed included the average cost per prescription and total medication purchases before and after implementation of the tiered formulary, which was phased in over several months and accompanied by intensive educational programs targeting physicians and pharmacy staff. Other outcomes included cost avoidance resulting from an increased emphasis on patient assistance program (PAP) enrollment and the use of "bulk replacement" arrangements for prescription replenishment. During a designated nine-month postimplementation period, the average cost per prescription declined by 4.7% (from $19.86 to $18.92) relative to the baseline value. Six-month spending decreases of 36-58% from prior-year levels were achieved in 7 of the 10 most-purchased drug classes, with an overall 25% decline in medication purchases. Cost avoidance due to more aggressive use of PAPs and bulk replacement programs also yielded substantial program savings. Formulary streamlining and other cost-control initiatives at an outpatient pharmacy program were associated with a decrease in the average cost per prescription of $0.94 over a nine-month period. The primary endpoint showed a potential annualized savings of approximately $1 million.
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Causal effects are defined as comparisons of potential outcomes under different treatments on a common set of units. Observed values of the potential outcomes are revealed by the assignment mechanism-a probabilistic model for the treatment each unit receives as a function of covariates and potential outcomes. Fisher made tremendous contributions to causal inference through his work on the design of randomized experiments, but the potential outcomes perspective applies to other complex experiments and nonrandomized studies as well. As noted by Kempthorne in his 1976 discussion of Savage's Fisher lecture, Fisher never bridged his work on experimental design and his work on parametric modeling, a bridge that appears nearly automatic with an appropriate view of the potential outcomes framework, where the potential outcomes and covariates are given a Bayesian distribution to complete the model specification. Also, this framework crisply separates scientific inference for causal effects and decisions based on such inference, a distinction evident in Fisher's discussion of tests of significance versus tests in an accept/reject framework. But Fisher never used the potential outcomes framework, originally proposed by Neyman in the context of randomized experiments, and as a result he provided generally flawed advice concerning the use of the analysis of covariance to adjust for posttreatment concomitants in randomized trials.
Chapter
In the United States, two patients with the same medical condition can receive drastically different treatments. In addition, the same patient can walk into two physician offices and receive equally disparate treatments. This chapter attempts to understand why. It focuses on three areas: the patient, the physician, and the clinical situation. Specifically, the chapter surveys patient or demand side factors such as price, income, and preferences; physician or supply side factors such as specialization, financial incentives, and professionalism; and situational factors including behavioral influences and systems-level factors that play a role in clinical decision-making. This chapter reviews theory and evidence, borrowing heavily from the clinical literature.
Article
We present the first systematic analysis of state policies limiting prescrip-tion drug access under Medicaid during 1990–2004, documenting their impact on states' Medicaid prescription spending growth. We see substantial variation in the number and type of policies used by states, but a clear upward trend in re-strictions over time. Analysis of state level annual spending growth shows that these restrictions have in general helped contain Medicaid prescription drug costs and that some approaches, such as the use of preferred drug lists (PDLs) and tiered copayment systems, may have been more effective than others.
Article
This chapter reviews the theory and empirical literature on physician market power, behavior, and motives, referred to collectively as the issue of “physician agency.” The chapter is organized around an increasingly complex view of the demand conditions facing a physician, beginning with the most simple conception associated with demand and supply, and building through monopolistic competition models with complete information, and finally models with asymmetric information. Institutional features such as insurance, price regulation, managed care networks and noncontractible elements of quality of care are incorporated in turn. The review reveals three mechanisms physicians may use to influence quantity of care provided to patients: quantity setting of a nonretradable service, influencing demand by setting the level of a noncontractible input (“quality”), and, in an asymmetric-information context, taking an action to influence patient preferences. The third mechanism is known as “physician-induced demand.” The empirical literature on this topic is reviewed. Theories based on alternatives to profit-maximization as objectives of physicians are also reviewed, including ethics and concern for patients, and the “target-income” hypothesis. The target-income hypothesis can be rejected, although there is empirical support for non-profit maximizing behavior.
Article
This article asks whether financial incentives can improve the quality of health care. A conceptual framework drawn from microeconomics, agency theory, behavioral economics, and cognitive psychology motivates a set of propositions about incentive effects on clinical quality. These propositions are evaluated through a synthesis of extant peer-reviewed empirical evidence. Comprehensive financial incentives--balancing rewards and penalties; blending structure, process, and outcome measures; emphasizing continuous, absolute performance standards; tailoring the size of incremental rewards to increasing marginal costs of quality improvement; and assuring certainty, frequency, and sustainability of incentive payoffs--offer the prospect of significantly enhancing quality beyond the modest impacts of prevailing pay-for-performance (P4P) programs. Such organizational innovations as the primary care medical home and accountable health care organizations are expected to catalyze more powerful quality incentive models: risk- and quality-adjusted capitation, episode of care payments, and enhanced fee-for-service payments for quality dimensions (e.g., prevention) most amenable to piece-rate delivery.
Article
Some doctors perform the dual roles of prescribing and dispensing pharmaceuticals. The dispensing doctors (DDs) role may give rise to prescribing behaviours that vary from those of non-DDs. The aim of this review was to systematically and comparatively appraise the research evidence related to the practices of DDs. A systematic search of bibliographic databases and reference lists from selected papers were the sources of the data. Inclusion criteria were papers published in English, between 1970 and 2008 that provided quantitative data comparing the practices of DDs and non-DDs. At least two of the authors abstracted data from all eligible papers using a purpose-made data extraction form. Twenty-one papers were included in this review. Evidence indicated that DDs prescribed more pharmaceutical items and less often generically than non-DDs. There was limited evidence to suggest that DDs prescribed less judiciously and were associated with poor dispensing standards. Patient convenience and access to pharmaceuticals were main reasons for doctors to dispense. DDs can fill an important gap in the provision of pharmaceuticals for their patients especially where health workforce shortages exist. There was evidence the dispensing role influenced prescribing. Patient convenience should be balanced against scarce medical resources, being utilised for dispensing.
Article
Several recent bills in Congress to add a Medicare prescription drug benefit would allow the use of formularies to control costs. However, there is little empirical evidence of the impact of formularies among elderly and disabled populations. We assess the effect of a closed formulary implemented by the Veterans Health Administration (VHA) in 1997 on drug prices, market share, and drug spending. We find that the VHA National Formulary was effective at shifting prescribing behavior toward the selected drugs, achieving sizable price reductions from manufacturers, and greatly decreasing drug spending.
Article
When Medicaid preferred drug lists (PDLs) are implemented, they may impose indirect costs on prescribing physicians and Medicaid patients, leading to an unintended reduction in the number of Medicaid prescriptions filled. To test retrospectively the proposition that PDLs adversely affect the number of Medicaid prescriptions filled. We compared three 'test' states (Alabama, Texas, and Virginia) that implemented PDLs with restrictions on the prescription of statins with three 'control' states (New Jersey, North Carolina, and Pennsylvania) that did not implement drug access restrictions. We conducted the analysis at the county level and used a differences-in-differences approach that allows for county and time-period fixed effects. We found that PDLs adversely impacted several measures of filled Medicaid prescriptions in the 'test' states relative to the 'control' states. There are unintended but potentially harmful consequences to cost-focused health policy interventions.
Article
It is difficult to keep control over prescribing behaviour in general practice. The purpose of this study was to assess the initial effects of a behaviour independent financial incentive on the volume of drug prescribing of general practitioners (GPs). 2-Year Controlled Before After study with an intervention region and a concurrent control region. GPs in two regions in the Netherlands (n = 119 and n = 118). A financial incentive for prescribing according to local guidelines on specific drugs or drug categories. The financial incentive consisted of a non-recurrent, behaviour-independent allowance. Change in the number of prescriptions for 10 targeted drugs or drug groups. Significant changes were seen only in three types of antibiotics and in recommended gastric medicines. In almost all cases, effects were temporary. Behaviour independent financial incentives can be a help in changing prescription behaviour of GPs, but effects are small-scale and temporary.
Article
To compare pharmaceutical spending and utilization in a consumer driven health plan (CDHP) with a three-tier pharmacy benefit design, and to examine whether the CDHP creates incentives to reduce pharmaceutical spending and utilization for chronically ill patients, generic or brand name drugs, and mail-order drugs. Retrospective insurance claims analysis from a large employer that introduced a CDHP in 2001 in addition to a point of service (POS) plan and a preferred provider organization (PPO), both of which used a three-tier pharmacy benefit. Difference-in-differences regression models were estimated for drug spending and utilization. Control variables included the employee's income, age, and gender, number of covered lives per contract, election of flexible spending account, health status, concurrent health shock, cohort, and time trend. Results. CDHP pharmaceutical expenditures were lower than those in the POS cohort in 1 year without differences in the use of brand name drugs. We find limited evidence of less drug consumption by CDHP enrollees with chronic illnesses, and some evidence of less generic drug use and more mail-order drug use among CDHP members. The CDHP is cost-neutral or cost-saving to both the employer and the employee compared with three-tier benefits with no differences in brand name drug use.
Causes and consequences of regional variations in health care
  • Skinner
Impact of three-tier pharmacy benefit structures on consumer attitudes, pharmacy, medical utilization and costs
  • Nair
Nair KV, Valuck RJ. Impact of three-tier pharmacy benefit structures on consumer attitudes, pharmacy, medical utilization and costs. Health Serv Res. 2009;44(3):988-1009.
Kein Arzt wird für seine teuren Patienten bestraft
  • H Korzilius
  • Wirtschaftlichkeitsprüfung
Korzilius H. Wirtschaftlichkeitsprüfung: "Kein Arzt wird für seine teuren Patienten bestraft". Dtsch Arztebl. https://www.aerzteblatt.de/archiv/89090/ Wirtschaftlichkeitspruefung-Kein-Arzt-wird-fuer-seine-teuren-Patientenbestraft. Accessed July 23, 2021.
Ärzte sollen angstfrei verordnen
  • H Korzilius
  • Arzneimittelrichtgrössen
Korzilius H. Arzneimittelrichtgrössen: Ärzte sollen angstfrei verordnen. Dtsch Arztebl. https://www.aerzteblatt.de/archiv/171584/Arzneimittel richtgroessen-Aerzte-sollen-angstfrei-verordnen. Accessed July 23, 2021.
Health system review
  • Busse