Do we need the “Old” Drug Formulary format in Barbados?

Colin Alert

Barbados

In his recent presentation of the 2010 to 2011 Budget, the Minister of Finance in Barbados Mr. Chris Sinckler noted that, from April 1st 2011, persons who have their prescriptions filled in private pharmacies will pay a dispensing fee as follows:

Table 1.

Drug cost. Amount to be paid by patient (Dispensing fee).
Under $ 10.00 $ 5.00
$ 10.01 to $ 20.00 $ 7.00
$ 20.01 to $ 40.00 $ 12.00
Over $ 40.00 30% percent of the cost of the drug.

(For drugs under $5.00, the dispensing fee will be greater than the drug cost, for drugs between $20.01 and $24.00, the dispensing fee will be more than half the cost of the drug.)

These dispensing fees will only be applied to drugs on the National Formulary, and only apply to patients who choose to have their prescriptions filled at the private pharmacies.

It is reasonable then to expect that, when a physician is about to prescribe, that some patients will ask: how much will that medicine /those medicines cost? Prior to April 1st 2011, many patients, particularly those with chronic non-communicable diseases like diabetes, hypertension, heart disease and hypercholesterolemia, obtained all their medications for these conditions free of cost. Patients with asthma also got a supply of anti-asthma medication free of costs, and the over 65 years got the medication for their arthritis free. But many patients perceive that different pharmacies attach different costs to the same medicines – perhaps we need drug-price inspectors, in the same way that we are supposed to have food price inspectors- and the patient would at least have a ball-park figure of his medication costs.

The 28th edition of the Barbados National Drug Formulary, which covered the period April 1st 2008 to March 30th 2009, listed drugs as followed:

Drug X

Indications: Disease yy. Used with ++++++++.

Cautions/Side Effects: Take with meals to decrease G.I. side effects. Monitor for hematological effects.

Dose Range: 15mg (base) daily for 14 days. May be used for up to 21 days.

Preparations:
Tablet, 25mg
Drug X (STP/COL); 0.0942 per Tab. (30)

In this case, a drug selected at random from the Drug Formulary 2009-2010, the listing shows, among other pieces of information, the cost of the drug, so that the physician could then work out the expected cost of a 14 (or 21) day course of drug X. Then, using table 1, the physician can advise a patient under 16 years and over 65 years how much they would be asked to pay (the dispensing fee) when they present the prescription to their private pharmacist. Patients between 16 and 65 years will have to pay both the drug cost and the dispensing fee.

On the other hand, the most recent edition of the Barbados National Drug Formulary (but not formally called the 29th edition), perhaps termed MPC # 31, a different format was used to lay out the drugs:

The Barbados Drug Service.
The following list shows the products which are currently contracted and those which will be available in the new contract.
Products Available in MPC # 30 Products Available in MPC # 31
4/1/2009 To 3/31/2010 1-Apr-2010 To 1-Mar-2011

Drug X
Drug X Tab (STP/COL) Drug X Tab (STP/COL)

The listing of drug X (the same drug was selected in both years) in MPC #30 excludes any important information on the drug, and importantly does not provide the physician with the information to advise the patient on drug costs.

Many patients, and perhaps many physicians, join the Ministers of Finance and Health in being very concerned about costs of the components of Health. In this context, there will be great interest in the cost patients will have to pay for their medications at the private pharmacies.

The Minister of Health, in his contribution to the budget debate, did suggest that efforts will be made to improve the public pharmacies. At the onset, many patients perceive the public pharmacies as places of prolonged waiting periods and an inadequate supply of medications. Many years ago, when a government appointed commission (“the Richie Haynes commission”) evaluated the Queen Elizabeth Hospital (QEH), they evaluated among other things the waiting periods at the Accident and Emergency Department. In spite of intermittent declarations of improvements of this Department, the experience of many patients (anecdotal evidence), the experience of private physicians who sometimes need to refer patients to the A&E Department, and the fact that the formal ‘waiting times’ evaluation has not been repeated (or at least made public, if it has), all suggest that there is no formal evidence to suggest improvement (and limited pieces of evidence all suggest deterioration). But if there is going to be claim of improvement in the public pharmacies, it must be formally evaluated, and perhaps compared to similar studies in the private pharmacies.

Similarly, the cost of saving on the dispensing fee has to be measured against possible fall off in medication usage, as many patients may be unable to pay these new costs for their medications ( while many other costs around them also rise).Costs may be shifted from primary care to the high cost Tertiary Care at the QEH, as patients suffer complication associated with a disruption in their therapeutic regimes.

A document from the Barbados Drug Service dated December 17th 2010 and titled “Revised Formulary “, lists a summary of the drugs that will be deleted from April 1st 2011, and these drugs will not be available free of costs to patients, and will no longer be stocked in public pharmacies. [This already tells us that the pharmacies will be “improved” by having them stock less drugs.] Like MPC # 31, there is no listing of prescribing information, and no listing of costs of drugs. This document lists 7 pages of drugs, currently available, that will no longer be available after April 1st 2011. Should any patient be particularly conscientious about drug costs, he/she may still have to attend the public pharmacies for the ‘free drugs’, and attend the private pharmacies for the ‘must pay for’ drugs. Since the elderly are the group most likely to be on multiple medications, they will be negatively affected in two ways: financially, as they will have to pay for many drugs [even though the Ministers of Finance and Health say that this is an unavoidable side effect of the world wide recession], and now having to wait, each month, in both a line at a public pharmacy and in a line at a private pharmacy to pay for their medications.

This “Revised Formulary” document also notes that the amendments “will have significant implications on overall prescribing”: this is a competitor for the understatement of the decade. In response to an epidemic of chronic diseases, physicians have been encouraged to follow Caribbean or International guidelines that set specific target blood pressures, blood sugars and cholesterol levels. These guidelines match disease and drug class, not disease and drug cost or availability. Now physicians are being asked to ‘familiarize yourself with the changes’, in a three month period, and ‘respond accordingly in your prescription writing’. The changes set out all the drugs that would no longer be available, and not the drugs that would be. We are being encouraged to ‘mix and match’ drugs to fit patient budgets and diseases. And we are yet to see what drugs will be on the formulary, and how much they will cost.

When the 2011 to 2012 Formulary comes out (if one does indeed come out) it is hoped that individual drugs and their costs are included. Patients are now being asked to pay for many medications for the first time; at least they should be informed about the costs they are likely to incur. Some patients may even have to decide, at the time when the prescription is being written, what medicines they can and can’t afford, irrespective of the consequences on individual health. In this context, we need the ‘old formulary format’, so physicians can be informed, and be able to to inform patients of the drug costs.