Generic drugs have the potential to provide significant cost savings in healthcare expenditure. As copies of brand-name originator drugs they can be mass-produced more cheaply without the associated research and development costs. And with various financial incentives also in place, their use could be expected to be significant. And yet, until recently, their use in Switzerland was well below the average for Europe. In an attempt to explain this, Decollogny et al. set out to understand the different possible influences on the use of generics in Switzerland, to see what was responsible for the low uptake. It appears that attitudes and beliefs on the part of patients and their physicians had a major effect on the decision of whether or not to prescribe generic medications.

Generic drugs contain the same therapeutic substance as the original formulation but are marketed at lower prices than the original brand-name drugs. Decollogny, Eggli, Halfon and Lufkin, at the Institute of Health Economics and Management, Centre Hospitalier Universitair Vaudois, and University of Lausanne, set out to explore the relationship between the use of generic drugs and its different possible influences.

Since 2001, Swiss pharmacists have been authorised to prescribe generic drug substitutes for originator products so long as they have the agreement of the patient and have informed the prescribing physician. Financial incentives were also introduced, such as a fixed fee for pharmacists per generic drug dispensed, and the obligation on patients to meet co-payments of up to 20% for the cost of brand-name drugs. However, in Switzerland, as in many other countries, there appear to be barriers, in practice, that limit the wider use of generics.

Studies elsewhere have identified various potential barriers to the uptake of generics, including patient concerns regarding efficacy and side effects, scepticism on the part of health professionals regarding clinical outcome, and loyalty to brands, as well as market conditions. To understand the factors at play in Switzerland, Decollogny et al. compared the situation in three regions (cantons) of Switzerland: Aargau, Ticino and Vaud, each representing one of the country’s three linguistic populations – German, Italian and French, respectively.

They used reimbursement claims data submitted by a total of 169,837 people to a large health insurer (CSS) during 2003. The authors performed logistic regression analysis to compare patients’ characteristics such as gender, age, treatment complexity, substitution groups, with other variables including physician variables, e.g. hospital specialist versus general physician, reimbursement incentives (optional health insurance deductibles, co-payments) and those affecting the generics market―packaging, price, number of available generics, and so forth. The generics they considered represented 298 substitution groups and corresponded to 20.4% of the total quantity of drugs delivered in 2003. This was low compared to the 40% to 60% market share of generics found in some OECD countries.

In the three cantons studied, they found the overall generics substitution rate to be 31%, but a tendency towards lower substitution for female and older patients, and in situations such as greater treatment complexity (more than 10 different drugs delivered in the same year). Factors that appeared to encourage a higher substitution rate included younger patients, higher out-of-pocket expenses, the presence of many generics options in a particular substitution group, many patients, and a larger difference in cost between generic and originator drugs.

The authors found that the attitudes and beliefs of physicians and patients were powerful influences on prescribing practices. They noted, ‘prescribing behaviours or beliefs about generics substitution may be as important as national policies.’ They found that hospital physicians, for example, substituted less than general physicians or private internists. The authors recommended that these individuals ‘should therefore be a focus of any future initiatives encouraging more effective outpatient prescribing practices.’

Patient attitudes were also a strong determinant affecting generics substitution, in particular, the worries of older patients, and those with more complex conditions such as hypertension, leading to greater reluctance to accept generic medications.

The authors concluded, ‘our findings highlight that policies on pricing and reimbursement are important as an impetus for the generic medicines market but not sufficient for a sustained generics market share.’ They recommended,  ‘educational approaches targeted at physicians should be investigated with a view to increasing their confidence in generics’ efficacy and safety.’

Editor’s comment
Readers interested to learn more on the patients’ perspectives of generics substitution in the western world between 2000 and 2011 with special emphasis on challenges for optimal drug use are invited to visit www.gabi-journal.net to view the following peer reviewed article published in 2012, Issue 1, in GaBI Journal:

A review of patient perspectives on generics substitution: what are the challenges for optimal drug use

If you are interested in contributing a research article in a similar area to GaBI Journal, please send us your submission here.

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Reference

1.  Decollogny A, Eggli Y, Halfon P, Lufkin TM. Determinants of generic drug substitution in Switzerland. BMC Health Serv Res. 2011 Jan,11:17.