Pii: s0168-8510(00)00066-xHealth Policy 52 (2000) 129 – 145 The cost of prescription medicines to patients Peter R. Noyce a,*, Christine Huttin b, Vicenzo Atella c, Gerhard Brenner d, Flora M. Haaijer-Ruskamp e, Maj-Britt Hedvall f, Reli Mechtler g a School of Pharmacy and Pharmaceutical Sciences, Uni6ersity of Manchester, Oxford Road, Manchester, M13 9PL, UK b European Institute for Ad6anced Studies in Management, 13 Rue d'Egmont, 1000 Brussels, Belgium/Uni6ersity of Paris X Nanterre, Paris, France c SEFEMEQ-CIES, Faculty of Economics, Uni6ersity of Rome-Tor Vergata, Via di Tor Vergata snc, 00133 Rome, Italy d Central Institute for Care Pro6ision, Honinger Weg 115, 50969, Cologne, Germany e Department of Clinical Pharmacology, Uni6ersity of Groningen, Antonius Deusinglaan 1, 9713 Groningen, The Netherlands f Swedish School of Economics and Business Administration, P.O. Box 479, 00101 Helsinki, Finland g Institute for Caring and Health Systems Research Johannes Kepler Uni6ersity, Altenbergerstrasse 69, 4040 Linz, Austria Received 22 February 1999; accepted 4 January 2000 The study compares the cost-sharing (co-payment) arrangements for prescribed medicines in a sample of EU countries. Through a set of typical prescription scenarios, the cost burdento individual patients of prescriptions are examined, in the context of drug price, and fromthe perspective of therapeutic need. The cost to patients of medicines is consistently lower insome, and higher in other, countries, regardless of the type of prescription charge system.
Fixed charge systems, as opposed to graduated co-payment systems, are obviously morelikely to lead to similar charges for the treatment of comparable clinical conditions, butdepending on the level of the charge, can result in the patient paying a higher charge thanthe price of the drug to the health organisation. Exemption from charges for prescriptionmedicines, commonly relate to clinical condition and level of income. Some systems alsohave age-related criteria and apply ceilings to the total prescription cost burden borne by thepatient. The impact on patient costs of specific policy formulations is discussed and a * Corresponding author. Tel.: + 44-161-2752413; fax: + 44-161-2752416.
E-mail address: [email protected] (P.R. Noyce) 0168-8510/00/$ - see front matter 2000 Elsevier Science Ireland Ltd. All rights reserved.
P.R. Noyce et al. / Health Policy 52 (2000) 129 – 145 proposal is made for cost convergence for comparable therapies. The method used in thisstudy may also provide a route for investigating model systems prior to implementation.
2000 Elsevier Science Ireland Ltd. All rights reserved.
Keywords: Pharmaceuticals; Prescription drugs; Co-payment; Cost-sharing; Prescription charges; Druguse The cost of health care, and particularly the cost of prescription medicines, present major challenges to public expenditure policies. EU Member states haveadopted a diverse range of approaches to cost-containment of pharmaceuticals onboth demand and supply sides. The prices of prescription medicines vary greatlybetween countries, but policies common to most, are systems for cost sharing thefinancial burden with consumers.
Burstall  argues that the purpose of prescription co-payments or charges is to restrain public spending on medicines, and there is a considerable body of evidence,particularly from the UK and USA, that shows the demand for prescriptionmedicines is reduced by a direct financial contribution from the patient . It istherefore important to formulate pharmaceutical reimbursement policies that donot jeopardize patients' needs.
Grootendorst  has shown that the onset of insurance cover for medicines was associated with an increase in drug utilisation, concentrated among patients withlower health status. Further, Stuart and Grana  in charting the impact of annualincome of an elderly population on their medication rates, have demonstrated thosein the lowest groups ( B$6000) were 25% less likely to medicate a given healthproblem than those in the top groups ( $18 000). EU Member States thereforecommonly have age and low income as grounds for exemption from cost-sharingarrangements for prescription medicines.
Most evaluations of co-payment systems [5 – 10] have concentrated on overall price elasticity, i.e. the impact of increases in patient contribution on the overalluptake of prescription medicines. However, recently it has been shown that priceelasticity can vary markedly between different therapeutic groups of drugs [4,11],raising concern about whether changes in cost-sharing arrangements affect theuptake of both essential and non-essential drugs similarly . Countries whichhave adopted new co-payment systems more recently, have been particularly keento explore their impact on the uptake of essential medicines in the evaluation oftheir systems [13,14]. Under the recently introduced Swedish system, some 20% ofhouseholds have attempted to attenuate the cost burden of prescription drugs. Themost commonly prescribed drugs where uptake was reduced by the implementationof the new co-payment arrangements were those for asthma, allergy, pain, gas-trointestinal ulcers and skin disorders. The greater the number of items prescribed,the more marked the reduction in uptake. The scheme has had the greatest impacton those on disability pensions or long-term sick leave, those with larger families(three or four children), single parents, students and the unemployed .
P.R. Noyce et al. / Health Policy 52 (2000) 129 – 145 This study differs from previous ones exploring prescription charge or reimburse- ment policies which have taken a system or population approach in a single countryor health insurance scheme. This international survey determines the cost ofprescribed medication at the level of the individual patient. The approach that hasbeen taken is to develop scenarios of hypothetical profiles of patients requiring drugtherapy for the treatment of common clinical conditions.
The purpose of the current study is to explore the cost to patients, in a sample of EU member states, of prescribed medication with a view to identifying: 1. factors determining the patient costs of prescribed medication and whether any trends are discernible between different types of cost-sharing schemes and/ordifferent countries; 2. the patient costs of comparable regimens of drug therapy;3. means of reducing the prescription cost burden to patients4. issues for consideration in the formulation of cost-sharing policies for prescrip- tion medicines.
The first challenge was to select for study a variety of prescription charge plans that reflected the diversity of systems within the EU. As a starting point, we selectedthe countries in which members were based of an existing EU funded-network, theEvaluation Network of Drug Expenditure and Policy (ENDEP), which included arange of fixed charge and graduated payment systems, and a variety of exemptionand compensatory mechanisms. The patient charge systems in the following coun-tries are described: Austria, Denmark, Finland, France, Germany, Italy, Nether-lands and the UK.
To explore the impact of the various systems on the cost burden of prescribed medication at the level of the individual patient, a set of 20 scenarios was devisedand piloted, each of which included a prescription for one or more products to treata common uncomplicated clinical condition — either acute, episodic or chronic.
The scenarios cover a typical range of domestic and social circumstances of patientsrequiring treatment from primary care physicians. They do not include scenarios ofelderly patients, who commonly suffer from multiple pathologies that require morecomplex drug regimens, and can be eligible for exemptions on a variety of grounds— age, income, clinical conditions, or have reached ceilings for prescriptioncharges. Their exclusion from this study does not suggest that either the cost ofdrugs to the elderly population is unimportant, or that it does not represent themajor cost burden for prescribed medication in EU countries, but rather that forthe purposes of this study their inclusion in the test scenarios would complicate and‘distort' the findings.
A limitation of the scenarios is that they do not incorporate any financial details, such as gross income, disposable assets, or receipts of social or welfare benefits orsubsidies. These are important because prescription charges may be waived indifferent countries, on the basis of low income or receipt of welfare benefits. The P.R. Noyce et al. / Health Policy 52 (2000) 129 – 145 assumptions made in these scenarios are that such exemptions do not apply. Theassumption is also made that within the scenarios, patients are subject to standardcharges, and that they have not reached prescription charge ceilings, in countrieswhere they apply, e.g. Germany. The absence of an income dimension to thescenarios means that exploration of the Dutch system was limited to its description,since the cost of prescription medicines at or below the reference price, are notshared with individuals below a certain income, and for those above, the co-pay-ment system depends on the health insurance scheme purchased.
Although prescribing behaviour varies between individual physicians, and na- tional prescribing patterns differ significantly, for the purposes of this study it isnecessary to exclude differences in costs arising from variations in prescribingpractices. Therefore the prescriptions within the scenarios are standardised andbased on contemporary UK therapeutic practice, and the products involved arethose licensed for use by the UK medicines regulatory authorities, and described inthe British National Formulary . They include products prescribed by the brandname of a particular manufacturer — and identified in the scenarios by invertedcommas — and those prescribed generically by their approved names.
Dispensing controls also vary across the countries included in the study. In many countries, pharmacists are required to supply medicines in original packs and todispense the number that most closely covers the number of dose units prescribed,whereas in UK, the exact number of dose units prescribed is dispensed. Some EUcountries limit prescribing and dispensing to branded products, e.g. France. Packsizes also vary between countries, as well as the available strengths of products.
Normal dispensing conventions in complying with prescribers' instructions wereassumed in each of the respective countries.
The prices of the prescribed medicines were derived from the standard prices listed in editions, current in July 1996, of appropriate publications in each country,i.e. Index of Medicines — Main Association of the Austrian Social Security(Austria); Drug Tariff (Finland); Red List of the Federal Association of Pharma-ceutical Industry (Germany); OEMF, L'informatore Farmaceutico (Italy); NHSList Price for branded products and Drug Tariff for generic products (UK).
No allowance was made for discounts on list prices in countries where these are formally incorporated, e.g. Italy and UK, but the standard handling charge of 0.45ecus was included in Finnish prices. For branded products, the medicine price usedin each country was that of the prescribed brand (or equivalent brand of the samemanufacturer) of the equivalent strength in the same dosage form, e.g. tablet,pressured aerosol, etc; and identical or nearest equivalent pack size. For genericprescriptions, the medicine price used was the price of the lowest cost product listedof the approved drug name, of an equivalent strength in the same dosage form andof the same or nearest equivalent pack size.
The patient charges were calculated by applying the prescription charge system operated in the respective countries, to products and packs that would normally besupplied by a dispensing pharmacist, in each country, in filling the prescriptions inthe scenarios.
P.R. Noyce et al. / Health Policy 52 (2000) 129 – 145 In the event, in 10 of the 20 scenarios developed, the products prescribed were unavailable in more than two of the countries surveyed or there was sufficientuncertainty about the comparability of products between countries for reliableinclusion in the study. Details of the individual prescription scenarios included inthe study are provided in Appendix A.
The survey of medicine prices and patient costs, using the ten standard prescrip- tion scenarios was undertaken in six of the countries in July 1996, and in Denmark,in October 1996. The Netherlands was not surveyed for the reasons explainedabove. The monetary values associated with prices and costs in each country wereconverted to ecus (now euros), using exchange rates listed in the 16 October 1996edition of The Financial Times. A comprehensive list of the prices of prescribedmedication associated with each of the scenarios is provided in Appendix B, andsimilarly a comprehensive list of patient costs in given in Appendix C.
3. Cost sharing schemes for prescription medicines in Europe
Table 1 provides details of the main features of prescription charge systems in eight EU member states. Three countries were included as examples of fixed pricesystems, i.e. Austria, Germany, UK. The UK is the simplest and easiest toadminister, with a flat rate charge per item. Austria has a fixed rate per pack, andtherefore the patient co-payment burden depends on the number of packs dis-pensed. Germany has three levels of co-payment depending on the pack sizes —small, medium and large — and so the total co-payment payable is dependant onthe size of the packs and the number of each pack size dispensed. Three countries— France, Denmark and Italy — have graduated systems, based on the designatedtherapeutic status of individual products. In France patients pay, either 0, 35 or65% of the cost of the prescribed products and in Denmark patients pay either 0,25 or 50% of the cost of the medicines prescribed. Italy also has a graduated system— 0, 50 and 100%, but other than for products in 100% band, a fixed prescriptioncharge per pack is also levied, similar to Austria. In Finland patients are normallyliable for the first 8.7 ecus of their prescription charge and refunded 50% of the costabove this deductible. For patients with serious long-term illness, the deductible ishalved, and the refund is either 75 or 100% of the prescription cost. In theNetherlands, prescription drugs are available under the public health system free ofcharge providing their price does not exceed the reference price. In 1996, an averageof 0.6 ecus per public insured person was paid to cover the cost of prescriptiondrugs above the reference price system.
Alongside different systems of cost sharing, there is a diverse range of exemp- tions. Exemption status may be gained from prescription charges or co-paymentson the basis of age, income, or clinical conditions. In some countries, the majorityof the population, are exempt. In UK, 85% of NHS prescription items — providedto over half the population are exempt from charges on the grounds of age(Scenario 5 and 9), income or clinical condition (Scenario 7). Extensive scope forexemption exists in France according to clinical condition. There is provision for Table 1Prescription charge arrangements within public health systems (July 1996) Ceiling on patient 0; 25; 50% of drug patients, through Graduated above a 8.7 ecus is standard 553 ecus in a year Low income patients fixed cost deductible can apply for full deductible of 4.35 ecus applies in seri- ous long-term illness 0; 35; 65% of drug 31 disease states; ‘Mutuelle' comple- Children up to 18 depending on pack years; low income generally, but 1% for chronically ill Graduated plus fixed cost plus 1.57 per disease state; low pack or full cost No charge for annual Zero unless drug income below 23 180 price is above refer- ence price system,when patient paysdifference Age, disease state, ment certificate atcost of 100.35 ecusannually a October 1996.
b In Finland, the above tariff is applied through a reimbursement system.
Table 2Range of drug prices and patient costs (1996) for prescribed medicationa Prescription scenario German price the highest, but the lowest cost to the patient.
Finnish cost is highest to patient French, German patients pay the lowest; Danish, British pay the most.
Only case where Finnish are not one of the highest British patients pay one of the highest costs with the lowest price,French Italian, German patients have the lowest costs Product not available in 4.20 (UK)–12.48(D) German price the highest, but the lowest cost to the patient; highest cost to Finnish patients. British patients pay more than the price 2.76(UK)–22.0 FL) UK, French, Italian, German patients pay less. Finnish pay the highest Cost divergence much larger than price divergence.
British patients do not benefit from lower prices 0(UK)–13.54 (FL) UK, French, Italian, German patients pay less. Austrian, 28.44 (F)–126.03(D) Germany highest price but lowest cost to the patient. Low price countriesdo not benefit the consumer. Danish and Finnish patients pay the most Patients are exempt on grounds of age in Germany and UK.
Patient cost low in Italy. Price of both products, and cost to patient highest in a A, Austria; D, Germany; DK, Denmark; F, France; FL, Finland; I, Italy; UK, United Kingdom.
b In parenthesis, are given the symbols of the European countries where the price or the cost to the patient is the lowest (Minimum) or the highest (Maximum) for the seven countries.
P.R. Noyce et al. / Health Policy 52 (2000) 129 – 145 exemption under 31 diseases, which require the prescriber's declaration (e.g. Sce-nario 10).
In Germany, exemptions can also be obtained on the basis of age (Scenario 9), and income: less than 10 600 ecus for singles, 14 400 ecus for couples annually. InNetherlands, there is no charge for prescribed medicines (costing no more than thereference price) under the compulsory sick fund scheme for employees and familieswho earn less than 23 180 ecus annually.
Several countries also have systems which cap the amount an individual has to pay for prescribed medicines in a year: In Finland, this is 553 ecus, whereas inGermany, total liability is limited to 2% of total income, and for chronically illpatients, 1%. In UK, pre-payment certificates can be purchased for 4- and 12-month periods, relieving holders of any further charges for prescriptions, regardlessof the amount of medicines prescribed.
For low income patients, both Denmark and Finland have schemes whereby the costs of prescription medicines may be refunded by local municipal authorities.
In France, the cost burden of prescription co-payments is reduced through a widespread system of complementary insurance coverage called ‘Mutuelles', whichcompensate the individual for costs associated with prescription medicines.
Table 2 records the range of drug prices and patient costs for scenarios 1 – 9.
(Scenario 10 is analysed in more detail in Table 3.) For both ranges, it indicates the Table 3Drug prices and patient costs of quadruple therapy for post-infarct patient (Scenario 10) (a) Total prescription Minimum list price Charge as % of costs (b) Individual prescrip- Minimum list price (ecus) % of drug price borne by Acetysalicylic Acid a Assuming all four items in the prescription were purchased at the same time. If they were purchased individually the total cost would be 43.86 ecus.
P.R. Noyce et al. / Health Policy 52 (2000) 129 – 145 countries with the minimum and maximum values for each prescription scenarioand comment is provided on the comparable patient costs of each scenario indifferent countries, and on any notable observations between drug cost and patientcharge.
There are wide divergences both in drug prices and patient costs for the selected prescription scenarios (Table 2, Appendices B and C). For some scenarios, the pricedivergence is larger than the cost divergence but in other cases the divergence inpatient cost is even larger than the price divergence. Countries with very high prices— Germany is often listed as the highest priced country out of the seven — do notnecessarily translate into high cost countries for the consumer. On the contrary, inseveral scenarios (e.g. 1 and 8) German prices are the highest but the costs to thepatient are the lowest.
British patients face in several scenarios (e.g. 1, 3 and 4) a very peculiar situation, since the drug prices are the lowest of the seven countries, but the British patientpays more than the price and sometimes amongst the highest prices.
4.1. The patient cost of comparable drug therapies Scenarios 1 and 2 (Fig. 1a) relate to middle-aged women in regular employment requiring medication for pain control — one for a sports injury and one formigraine. Scenarios 3 and 4 (Fig. 1(b)) involve short courses of treatment forinfections in young women. Scenarios 5 and 6 (Fig. 1(c)) address long term drugtherapy requirements intended to prevent serious future morbidity, i.e. cardiovascu-lar crises and osteoporosis.
Within these illustrative six scenarios, the patient cost of prescribed medication in France, Germany and Italy is generally less than that in the other four countries,except when exemptions come into play. In France and Italy the lower patient costis attributable to lower drug prices and in Germany because the co-payment is onaverage a substantially smaller proportion of the drug price. Patient costs inFinland are consistently higher than in other countries in the three sets of scenarios.
In countries with a fixed charge system (e.g. Austria, Germany and UK) patientcharges for comparable drug therapies are obviously more likely to be the same (seeFig. 1) whereas in other countries the cost of drugs for similar conditions aremarkedly different, since they reflect the prices of the prescribed products.
4.2. Multiple drug therapy Scenario 10 — concerning a post-myocardial infarct patient — provided us with an opportunity to explore the impact of patient charge systems on multiple drugtherapy in the individual patient. From a clinical viewpoint each product providesa separate and necessary component of the contemporary drug management ofpatients following a myocardial infarct. Each is important in preventing theoccurrence of a further ‘heart attack' leading to further incapacity or death.
However only in Austria and UK is the cost to the patient for 1 month's treatmentthe same for each of the four drugs (Fig. 2). Table 3(a) demonstrates that there is P.R. Noyce et al. / Health Policy 52 (2000) 129 – 145 Fig. 1. Cost to patient (ecus) of prescribed medication: (a) scenarios 1 and 2. (b) scenarios 3 and 4.
*Products in senario 4 not available in France or Italy. (c) scenarios 5 and 6. *within scenario 5, patientsare exempt from prescription charges in the UK. +Data not available a greater order of diversity of patient costs than drug prices for the full prescrip-tion, and that patients in Finland and UK would bear the major share of the costs.
The greater diversity of costs over prices is in fact reflected in each of the P.R. Noyce et al. / Health Policy 52 (2000) 129 – 145 components of the prescription (Table 3(b)), and in Italy and UK, the patient canpay significantly more than the list price. (Low-dose aspirin has been included inthis scenario for illustrative purposes, and in UK at least, it is unlikely that patientswould actually pay a prescription charge for this item because they would normallybe advised to buy the product over-the counter from pharmacies, since the purchaseprice is less than the prescription charge).
5.1. Determining the impact of different pharmaceutical reimbursement policies The investigation of the differential impact of cost-sharing systems on the uptake of different therapeutic groups of prescription drugs is a recent development .
Policy-makers still rely on post-implementation surveys to determine the effect ofnew pharmaceutical reimbursement schemes on patterns of consumption of pre-scription medicines [13,14]. Ideally, models of cost-sharing schemes should be testedbefore implementation, using an evaluation instrument encompassing drugs acrossa wide therapeutic spectrum and patients in a variety of socio-economic circum-stances. The approach adopted in this study of using patient scenarios, incorporat-ing common clinical conditions and appropriate prescriptions, provides a start inthis direction.
In pursuing this approach, the following factors are helpful to note: Choice of clinical conditions — these need to be selected to cover a variety ofwell-defined conditions amenable to drug therapy, ranging from the self-limiting tothe incapacitating and life-threatening, and with a comparatively high prevelancewithin the population under study.
Fig. 2. Cost ecus to post-myocardial infarct patient of multiple drug regimen (scenario 10). *Assumingall 4 items were purchased simultaneously. +Within this senario, patients were exempt from prescriptioncharges in France.
P.R. Noyce et al. / Health Policy 52 (2000) 129 – 145 Choice of prescribed regimens — these should represent evidenced-based, currentlyrecommended drug therapy derived from standard prescribing references and/orcondition-specific consensus guidelines. Only half of the original scenarios de-vised for use in this current European study could in the event be used eitherbecause of the unavailability of particular products in some countries or uncer-tainty in the comparability of products. Therefore, in international studies it isimportant to devise prescription scenarios based on an awareness of consump-tion data of different brands, dosage forms and packs.
Socio-economic components of scenarios — scenarios need to incorporate a variety of patient ages, social circumstances and clinical histories. The scenariosin the present study were found wanting in their lack of detail on income,economic circumstances and expenditure on prescription medicines.
Specifically designed batteries of scenarios could be devised to investigate the impact of specific exemption criteria including for instance, the introduction ofcharge ceilings, or to consider the impact of cost-sharing schemes on particularsocial or disease groups.
5.2. Comparing costs and treatments This study begins to explore the patient cost burden of comparable treatments within different national pharmaceutical pricing and cost sharing schemes. Wehave used the comparators of the treatment of acute infections and pain reliefand also considered the patient cost of long-term medication, using antihyperten-sive and hormone replacement therapy (HRT) regimens as examples.
Fig. 1 confirms that the patient's cost burden for prescription medicines is consistently lower in some countries than in others. It also shows that patientcosts of comparable drug treatment regimens are more likely to be similar withinfixed charge systems.
Other recent studies [4,11] have considered both the importance of patient income and type of therapy on the impact of patient charges on uptake ofprescribed medicines. A retrospective study of elderly beneficiaries of the Penn-sylvania Medicare programme  demonstrated that not only were those withthe lowest income level least likely to medicate, but there was a significantdifferential price elasticity across different therapeutic groups (presumably) basedon patients' perceptions of therapeutic importance.
The significance of our findings in the context of these two studies is that patients are likely to make decisions about paying for, and therefore usingprescribed medicines, on the basis of their own economic circumstances, the costburden of prescribed medication, and their judgement of the clinical benefit ofthe individual drugs prescribed. Therefore, in a situation where composite drugtherapy is deemed clinically necessary (Fig. 2 and Table 3), patients in modestfinancial circumstances may well be selective in the prescription drugs they useon the basis of the cheapest and their — rather than the clinician's — percep-tion of the most important.
P.R. Noyce et al. / Health Policy 52 (2000) 129 – 145 5.3. Patient costs This study does not pretend to draw clear conclusions about pharmaceutical prices or patient charges for prescribed medicines in Europe since the number ofscenarios is very limited and is confined to seven countries. However this series ofcase studies does provide a flavour of the complexity of European price structuresand the diversity of the impact of prescription drug reimbursement systems. Insome countries, the costs to patients of prescription medicines are consistentlycheaper, and in others generally higher (see Table 2 and Fig. 1). No account hasbeen taken in this study of the cultural factors relating to health care or its cost, orof comparable average national incomes. Although these will have some bearing,they do not affect the essence of these general observations on country-to-countryvariation of prescription costs in the seven EU member states.
The cost to the patient of prescribed medicines in a graduated co-payment scheme is a product of the drug cost, the co-payment banding and the designationof therapeutic groups to co-payment bands. Therefore changes to either the drugprice control mechanism or to the patient co-payment system will affect the cost tothe patient. Within fixed charged schemes, the price to the patient of prescribedmedicines is independent of the drug cost, but the gearing between the two will beof interest to health resource managers and policy-makers, if not directly to theconsumers.
Where the patient charge depends on the number of packs and/or size of the packs, prescribing decisions are pivotal, since the patient cost depends on thequantity prescribed and therefore the period of the prescription. In the graduatedpercentage systems, the length of the prescription is immaterial to the cost burdenfor long-term patients and, indeed, some countries (e.g. France and Italy) limit theperiod of a prescription. However, in fixed charge systems, longer prescriptions arelikely to result in a lower cost burden for patients (e.g. in scenario 8 the UK patientwho received his medicines in monthly, rather than three-monthly, instalmentswould pay three times the cost). Again in systems where a deductible is levied oneach prescription (rather than each medicine), costs are minimised by purchasing allprescribed medicines together and for longer periods. There is a 24% difference inthe cost to Finnish patients in purchasing all prescribed medicines in Scenario 10together, rather than individually.
5.4. Exemptions and refunds Exemptions and refunds are on the one hand designed to avoid or attenuate the barriers to necessary drug therapy that prescription charge systems impose. On theother, they remove any brake on consumer demand and a significant constraint onunnecessary access to medicines. In countries, such as UK, where non-prescriptionmedicines can be prescribed under the National Health service, exemption fromprescription charges provides a strong incentive to obtain them on prescriptionrather than purchase them directly from the pharmacy and so incur the full cost. Therefore exemptions and refund systems, unless there are formulary or ‘Black P.R. Noyce et al. / Health Policy 52 (2000) 129 – 145 List' limitations, may lead to the national health system shouldering an unnecessaryburden of minor illness in terms of drug costs and professional time.
6. Policy implications of this study
Changes in prescription charges or reimbursement arrangements in EU countries generally command extensive media coverage [17,18], but comment is usuallylimited to policy considerations. What is important to patients, is the effect on thecost of their prescriptions, and whether they can afford them. The use of patientscenarios provides a method to study the impact of changes to cost-sharingarrangements at the level of the individual patient, and a possible route toevaluating models of pharmaceutical reimbursement prior to implementation.
The findings of this study have the following implications for policy formulation.
Evidence from earlier work [4,13] suggests that the diversity found in this study inpatients' costs arising from treating the same or similar clinical conditions withdifferent prescribed medicines, may result in patterns of consumption at odds withclinical need. A move towards convergence of patient costs, for comparabletherapies, could be achieved through a combination of a reference price system fordetermining the price of drugs within therapeutic groups, such as currently exists inGermany and the Netherlands, with patients' contributions being determined by agraduated co-payment scheme related to the therapeutic importance of the product,such as currently exists in France.
A policy of generic prescribing within graduated co-payment schemes, would reduce the cost burden on the patient and could significantly improve the uptake ofprescribed medicines, as well as achieve savings for the drugs bill.
With fixed charge schemes, policy limitations on the length of prescriptions may significantly increase the cost of prescribed medication to patients with chronicdisorders.
We acknowledge funding from the European Commission under its Human Capital and Mobility, and Biomed 2, programmes and organisational support fromthe European Institute for Advanced Studies in Management (EIASM), Brussels.
Appendix A. Prescription scenarios
1. A 42 year old female married teacher — who teaches history in a state-funded school for girls aged 11 – 18 — sprained her ankle whilst playing tennis withher neighbour outside of school hours. Her husband is a self-employedarchitect. Prescription: ‘Synflex' two twice daily after food. Supply sufficientfor 5 days.
P.R. Noyce et al. / Health Policy 52 (2000) 129 – 145 2. A 35 year old female bus driver suffers from migraine — averaging one attack per month — for which she carries medication to use immediately at the onsetof an attack. Prescription: ‘Cafergot' one or two at onset of attack and up totwo as required over the next 24 h. Supply 20.
3. A 23 year old single woman, who lives with her 2 year old daughter, in municipal rented accommodation, and works part-time (15 h per week) as anoffice cleaner has developed an acute chest infection for which she requires acourse of antibiotics. Prescription: Amoxycillin 250 mg three times daily. Sendsufficient for 5 days.
4. A 21 year old psychology undergraduate student who is attending a state university and is financially supported by her parents, recognises from hersymptoms — which mimic those that she experienced once before 15 monthsago — that she has vaginal candidiasis, for which she requires treatment.
Prescription: ‘Canesten I' to be used at night.
5. A 62 year old legal clerk, living with his second wife and three teenage children, has been treated for hypertension for 5 years. Prescription: Atenolol50 mg one daily for 2 months.
6. A 50 year old non-working grandmother who lives with her 54 year old husband — who is an ex-psychiatric nurse who retired early two years ago —requires hormone replacement therapy after having a hysterectomy 4 yearsago. Prescription: ‘Estraderm TTS 50' one to be applied twice weekly. Supplysufficient for 1 month.
7. A 28 year old housewife, married to a factory worker, has been diagnosed as suffering from post-natal depression 10 weeks after the birth of her secondchild- for which antidepressant therapy is required. Now 12 weeks postpartum, the dosage is being increased to a full therapeutic level. Prescription:Imipramine 25 mg two three times daily. Supply sufficient for 4 weeks.
8. A 27 year old hospital porter lives with his partner — who is a medical records clerk in the same hospital — their 3 month old son and her 3 year old son. Thepatient was diagnosed as suffering from mild ulcerative colitis 9 months agofor which he is now receiving routine maintenance therapy. Prescription:Sulphasalazine 500 mg four times daily. Supply sufficient for 3 months.
9. An 18 year old schoolboy — whose father is a full-time swimming instructor and coach, and mother is a part-time cashier at the local leisure centre —suffers from exercise-induced asthma, i.e. Adult Step/2, which was diagnosed10 years ago. He requires routine maintenance therapy. Prescription: (a)‘Becotide-200' × 2. Two puffs twice daily. (b) Salbutamol inhaler. One – twopuffs before exercise.
10. A 53 year old divorced male executive is recovering at home after suffering a myocardial infarct 4 weeks earlier. He is in the care of his daughter who is 25years old, single and unemployed. Prescription: (a) ‘Capoten' 12.5 mg twicedaily. (b) Frusemide 40 mg once daily. (c) ‘Zocor' 10 mg one at night. (d)Aspirin 75 mg two daily. Supply sufficient for 4 weeks.
P.R. Noyce et al. / Health Policy 52 (2000) 129 – 145 Appendix B. Minimum list prices of prescription ingredients (ecus)
(A) Prescription product not marketed in France and Italy.
(B) Data unavailable.
Appendix C. Cost of prescriptions to patient (ecus)
(A) Prescription product not marketed in France and Italy.
(B) Data unavailable.
P.R. Noyce et al. / Health Policy 52 (2000) 129 – 145  Burstall ML. Co-payments for medicines — how much should patients pay? Pharmacoeconomics 1994;6:187 – 92.
 Huttin C. The use of prescription charges. Health Policy 1994;27:53 – 73.
 Grootendorst PV. A comparison of alternative models of prescription drug utilization. Health Econ 1995;4:183 – 98.
 Stuart B, Grana J. Ability to pay and the decision to medicate. Med Care 1998;36:202 – 11.
 Leibowitz A, Manning W, Newhouse J. The demand for prescription drugs as a function of cost sharing. Soc Sci Med 1985;21:1063 – 9.
 Soumerai SB, Avorn J, Ross-Degnan D, Gortmaker S. Payment restrictions for drugs under Medicaid: Effects on therapy, cost and equity. New Engl J Med 1987;317:550 – 6.
 O'Brien B. The effect of prescription charges on the utilization of prescription medicines. J Health Econ 1989;8:109 – 32.
 Harris BL, Stergachis A, Ried LD. The effect of drug co-payments on utilization and cost of pharmaceuticals in a health maintenance organisation. Med Care 1990;28:907 – 17.
 Ryan M, Birch S. Charging for health care: evidence on the utilization of NHS prescribed medicines. Soc Sci Med 1991;33:681 – 7.
 Hughes D, McGuire A. Patient charges and the utilization of NHS prescription medicines: some estimates using a co-integration procedure. Health Econ 1995;4:213 – 20.
 Lundberg L, Johannesson M, Isacson DGL, Borgquist L. Effects of user charges in different socio-economic groups. Health Policy 1998;44:123 – 34.
 Freemantle N, Bloor K. Lessons from international experience in controlling pharmaceutical expenditure. I: influencing patients. Br Med J 1996;312:1469 – 71.
 McManus P, Donnelly N, Henry D, Hall W, Primrose J, Lindner J. Prescription drug utilization following patient co-payment changes in Australia. Pharmacoepidemiol Drug Saf 1996;5:385 – 92.
 Bergmark, E. Change in reimbursement system in Sweden. In FIP '98 Abstracts (Pharmacy World Congress '98, The Hague, 30 August – 4 September 1998), International Pharmaceutical Federation,The Hague, 1998. p. 13.
 British National Formulary Number 31. British Medical Association/Royal Pharmaceutical Society of Great Britain, London, March 1996.
 Payne K, Ryan-Woolley BM, Noyce PR. Role of consumer attributes in predicting the impact of medicines deregulation on National Health Service prescribing in the United Kingdom. Int J PharmPract 1998;6:150 – 8.
 Higher co-payments for patients: the coalition votes for the reform of the health care system, Frankfurter Allgemeine, 21 March 1997. p. 1 – 2.
 Brindle, D. Analysis — Prescription charges: Labour shoots itself in the foot — and takes the tablets; The Guardian, 3 March 1998. p. 13.
Nephrol Dial Transplant (2005) 20: 441–443doi:10.1093/ndt/gfh297 Treatment of baclofen overdose by haemodialysis: a pharmacokineticstudy Vin-Cent Wu1,2, Shuei-Liong Lin2, Shu-Meng Lin3 and Cheng-Chung Fang3 1Department of Internal Medicine, Far Eastern Memorial Hospital, 2Department of Internal Medicine and 3Departmentof Emergency Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei,Taiwan
GalanterKrishnan25 4/6/2004 12:19 PM "Bread for the Poor": Access to Justice and the Rights of the Needy in India† Marc Galanter* & Jayanth K. Krishnan** India is rightly acclaimed for achieving a flourishing constitutional order, presided over by an inventive and activist judiciary, aided by a proficient bar, supported by the state and cherished by the public. At the same time, the courts and tribunals where ordinary Indians might go for remedy and protection are beset with massive problems of delay, cost, and ineffectiveness. Potential users avoid the courts; in spite of a long-standing reputation for litigiousness, existing evidence suggests that Indi-ans avail themselves of the courts at a low rate and the rate seems to be falling.1 Still, the courts remain gridlocked.2 There is wide agreement that