Are medical cards the best way to deal with drug costs?

Many of our older readers will recently have received medical cards for the first time, following the Government's decision to extend eligibility for free medical services to all over-70s.

Many benefits accrue from access to the General Medical Services Scheme, not least of them free medication. And while many recipients will have used the drug-cost subsidisation scheme as private patients, in effect limiting the cost of regular monthly prescriptions, the new medical-card holders are now £42 a month better off.

In an important development, the Department of Health and Children and the Irish Medical Organisation have agreed that the new over-70s cards will be "budget neutral".

This means that doctors prescribing for these patients will be able to do so outside a controversial indicative drug budgeting scheme that applies to all other medical-card holders.

The system works like this: medical-card lists are subject to an annual drug budget set by the health boards, based on patient profile and on the list-holding doctor's prescribing habits.

Doctors receive regular bulletins suggesting how they can improve their performance, such as by substituting a generic product for a more expensive branded version of the same drug.

While there are no penalties for doctors who exceed their drug budgets, there are significant advantages for those who achieve savings.

The health boards pay back a proportion of the "saved" money to doctors to invest in the infrastructure of general practice - enlarging premises or buying medical equipment, for example.

Many doctors are uneasy about the budgeting scheme. A Wexford GP, Dr Reggie Spelman, writing in a recent edition of the Irish Medical Times, has called for the indicative drug budgeting scheme to be scrapped.

While accepting that generic prescribing is an appropriate way of making drug savings, Spelman felt that other aspects of the scheme raised concerns.

"These concerns mainly centre on the problem of inappropriate therapeutic substitution and were raised by a consultant cardiologist at a clinical meeting I attended. The cardiologist outlined the benefits of good 24-hour control of blood pressure.

"The savings to the health service (not to mention the quality of life of the patient) by a reduction in strokes alone was more than compensated for by using more expensive antihypertensives with a 24-hour action."

What frustrated the heart specialist was seeing patients discharged from hospital with excellent blood-pressure control, having been prescribed a long-acting (and more expensive) drug, only to see them return after being switched to cheaper medication that is of the same type but needs to be administered three times a day.

Blood-pressure control was frequently lost, probably as a direct result of patients not following their prescriptions properly because of the need to remember to take a tablet three times a day instead of once.

And while neither Spelman nor the cardiologist spelt it out in such blunt terms, what would the ultimate cost be, both to the individual and the health service, of such a patient suffering a stroke as a result of avoidably elevated blood pressure?

Spelman also made the point that savings in General Medical Services Scheme drug costs are "not being reflected" in the drug-cost subsidisation scheme.

In other words, prescription trends for private patients do not seem to reflect those for the medical-card population.

The difference is the result of doctors behaving unconsciously, according to the Wexford GP.

A phenomenon called the Hawthorn effect, in which the knowledge that an aspect of one's behaviour is being audited may change the outcome, is almost certainly at work here.

Spelman reasonably suggests that prescriptions in both schemes be audited for certain quality markers. The level of usage of preventative drugs such as statins, which lower cholesterol, and long-acting bronchodilator inhalers, which prevent asthma flare-ups, would be a good indicator of a level prescribing playing field.

In a hard-hitting end to his article, Spelman outlines an "appalling vista" in which clusters of strokes and coronaries will occur.

"Will it transpire that these clusters are found in those practices that made the most savings? Many years hence, will yet another tribunal be set up to investigate this scheme and its consequences? Will it not be asked why this scheme indicative drug budgeting was not fully audited or subjected to a controlled trial with outcome measures other than cost alone?"

It is a reasonable question, and one that politicians and health administrators should address in the interests of equity and accountability.

You can e-mail Dr Muiris Houston, Medical Correspondent, at mhouston@irish-times.ie or leave a message on 01-6707711, ext 8511. He regrets he cannot reply to individual medical problems