By: Liz Gill, Anu Helkkula, Nicola Cobelli, and Lesley White
Published in the International Journal of Pharmaceutical and Healthcare Marketing
Vol. 4 No. 4, 2010
Abstract
Purpose – The substitution of generic prescription medicines for branded medicines is being practiced in most westernized countries, with evidence of a strong focus on evaluating and monitoring its economic impacts. In contrast, the purpose of this paper is to explore the generic substitution experience of customers and pharmacists in a pharmacy practice setting.
Design/methodology/approach – The study applied a phenomenological method using the narrative inquiry technique combined with critical event analysis, in order to understand the generic medicine experience as perceived by customers and pharmacists as key substitution actors. Interviews were conducted with 15 pharmacists and 30 customers in Australia, Finland and Italy, using a narrative inquiry technique combined with critical events and metaphors.
Findings – The findings show that customers, with poor awareness of generic prescription medicine when offered as a substitute, were likely to become confused and suspicious. Pharmacists related how they felt challenged by having to facilitate generic substitution by educating unaware customers, in isolation from both the prescribing doctor and the government/insurer. They also experienced frustration due to the mistrust and annoyance their customers displayed.
Social implications – The findings suggest that to increase generic substitution, open dialogue is paramount between all the participants of this service network, along with the development of targeted promotional materials.
Originality/value – Little is known about how customers and pharmacists experience the service phenomenon of generic medicine substitution. This paper explores how the key actors at the point of substitution make sense of the process. Additionally, the methodology provides a technique for obtaining a deeper understanding of both the customer and pharmacist experience of generic medicine, along with insights into how the uptake of generic medicine might be improved.
Generic medicine substitution in Australia, Finland and Italy
Prescription medicines in Australia, Finland and Italy are government subsidised, with generic medicines costing the public purse less than their branded equivalent. Whilst there are differences between these countries in the prescribing, substitution and pricing policies and regulation mechanisms for generic medicines, all three governments continue to sponsor their uptake. Significant differences are evident between the three countries in the market share of generic prescription drugs which, it is suggested, are potentially due to the different approaches the respective governments have adopted. In 1994 in Australia, changes were introduced to permit pharmacists to substitute generic prescription drugs if they were listed on the Schedule of Pharmaceutical Benefits, yet by 2001 generics accounted for only 20 percent of all prescriptions filled, and by 2004/2005 it had grown to only 25 percent (Beecroft, 2007). When compared with other comparable countries, this percentage is relatively low (Lofgren, 2004).
Generic drug substitution was formally introduced into Finland in 2003 (Aalto-Seta¨la¨, 2008); it had however been brought in as a voluntary form in 1993, but because of insignificant use, it was abandoned in 1996 and was replaced by generic prescribing which in turn was also rarely used (Martikainen and Rajaniemi, 2002). The 2008 reform was implemented through the Finnish regulatory authority setting the maximum wholesale price and retail markup for government reimbursed pharmaceuticals, so where a prescribed drug is more expensive, the pharmacist must recommend generic substitution to their customer (Heikkila¨ et al., 2007). According to the Association of Finnish Pharmacies, only one out of ten customers refused to substitute the prescribed brand medicine for a generic (Heikkila¨ et al., 2007). However, in April 2009, Finland withdrew the subsidy for brand medicine where a generic medicine alternative is available, unless specified by the doctor. This is expected to further increase the uptake of generic medicines.
In 1996, Italy launched generics with Decreto Legislativo 323, requiring the price of generics to be 20 percent lower than patented drugs; and in 2001, pharmacists were given the right to substitute. Yet, despite structural reforms to increase competition
between equivalent products, the generic share of public pharmaceutical expenditure
has remained largely unchanged (Ghislandi et al., 2005). Statistics published by the Italian Medicine Agency (Agenzia Italiana del Farmaco) in 2008, show that the substitution of generics had grown to 49 percent, from 33 percent in 2002.
Customer perspectives on generic medicine substitution
Hassali et al. (2009) identified 20 customer-focused studies concerning generic
medicines that had been conducted between 1970 and 2008. Some of these studies
demonstrated that both affordability and access were key dimensions that customers
used to develop their attitudes about drug benefits, and that poor physician communication skills could be used to predict negative customer generic drug beliefs
(Deselle, 2001; Motheral and Heinle, 2004). Customer resistance arises due to poor
understanding of the main concepts behind generic medication, especially when
customers, used to particular drugs, are introduced to an equivalent drug that has a
different name and appearance (Al-Gedadi and Hassali, 2008). In their customer study,
Ganther and Kreling (2000) found that the proportion of respondents who perceived that
generic prescription drugs were riskier than brand-name drugs was dependent on their
health condition. Further, customer preferences have been shown to have a significant
influence on doctors’ prescribing practice (Kravitz et al., 2005), and counseling
customers about generics has demonstrated a greater uptake of these drugs (Ganther
and Kreling, 2000; Himmel et al., 2005; Pereira et al., 2005; Valle`s et al., 2003; Van Wijk et al., 2006), with general medical practitioners being in an ideal position to reduce
customer anxiety about generics (Ringuier et al., 2008).
Conclusion
This study has specifically explored the experiences that customers and pharmacists
confront in the process of generic prescription medicines substitution, with the voices of
customers and pharmacists from three different countries clearly similarly evidencing
customer confusion when dealing with sense making of the phenomenon of generic
medicine and their respective roles. Until recently, customers have played a largely
passive role as recipients of prescription medicine, but with the advent of generic
substitution, customers potentially have become empowered to be more active in
co-creating the service. Importantly, Prahalad and Ramaswamy (2004) point out that
service value is individually experienced, and co-created by the actors; with the building
blocks of co-creation being dialogue, information access, risk assessment and
transparency. The success of empowering the pharmacy customer has ostensibly
been compromised by the inadequacy of information and the resultant uncertainty and
frustration they are experiencing. Pharmacists in Australia, Finland and Italy have
described how they would like to see customers well informed about generic medicines;
but critically customers are not being empowered with the knowledge that is the
primary prerequisite for service co-creation. The benefit of educating pharmacy
customers is supported by the work of Valle`s et al. (2003), who assessed the acceptability of substitution of brand-name drugs for generic drugs by customers with chronic illnesses in Barcelona and found that instructing customers individually, at the repeat prescribing interface, resulted in a 98.9 percent acceptance of generic substitution. Importantly, Shrank et al. (2009), as a result of their study of customer perceptions, recommended further education, “rebranding” of generic medications, improved communication with prescribers, or the adoption of zero dollar co-payment programs, to increase substitution.
The study contributes to pharmaceutical and healthcare marketing research by
identifying customer and pharmacist experiences expressed through their narratives.
It specifically asked customers and pharmacists in three different countries to relate a
critical event that they had experienced with the generic prescription medicine
substitution process, in order to understand its effects. The main implication of this
study is that if customer unawareness, confusion and suspicion are to be addressed,
and an increase in the substitution of generic medicine is to be achieved, specific
consideration must be given to determining the best means of educating customers.
The customer and pharmacist stories in this study indicate that currently that role falls
on pharmacists, with the task of promoting the uptake and gaining customer acceptance
of generic substitution being left largely to the point of sale pharmacist. This research
clearly demonstrates that pharmacists are confronted with significant resultant
difficulties, as they are effectively performing this role in isolation from both the
prescribing doctor and government/insurers. The pharmacists identified that there was
a disconnect between them and the prescribing doctors, potentially resulting in
disadvantage to the end-user.
Article Source: https://helda.helsinki.fi/dhanken/bitstream/handle/10138/37227/Gill_Helkkula_Cobelli_White_2010.pdf?sequence=2
Image: VCG
Analysis:
My overall reasoning for adding this article to our pharmaceutical literacy research was that it shows that there are problem spaces within the pharmaceutical industry that result in pharmaceutical illiteracy. First, the study shows that there is an overall disconnect between the pharmacist and the prescribing doctor, and this causes the pharmacist to seem more like a point of sale last-step seller than an educated professional here to help the public. Second, there is an overall issue with trust in the pharmaceutical world, in which generic brands and medication that has multiple alternatives or names can confuse, scare, and cause anxiety to the public. It was interesting to see how Australia, Finland, and Italy approached generic brands in the pharmaceutical industry vs. the western world. In the western world, generic brands are much more common, however, they may stir up just as much confusion as they do in these places. Overall, this was a good case study on how the in-pharmacy experience matters, and how that experience can hinder pharmaceutical literacy.
