Should doctors have the right to dispense the medicines they prescribe? This long-running debate was recently put to rest, when separation of the two functions became compulsory. But there is much at stake, and controversy continues.
“Taiwan’s population is to medicines what children are to candy.” Given a degree of hyperbole, this local resident’s judgment pretty much sums it up. Take so-called flu syrup, for example. Especially popular among the elderly, most households stock at least one bottle for consumption at the onset of headache, toothache, back pain, fatigue, fever, or most any other physical complaint. At approximately 70 cents a bottle, this syrup, which often contains caffeine, acetaminophen, and sometimes the addictive drug codeine, is a cheap, easy-to-come-by and easy-to-swallow panacea, held in much the same esteem as aspirin in the West. It has its darker uses, too--some drug addicts swig it as an inferior alternative to their usual poison. One sales representative familiar with the market estimates that Taiwan’s population consumes between 30 and 40 million bottles of flu syrup every year.
The local fondness for medication is so pronounced that tourists coming home from a trip abroad will often pack medicines to give as presents to friends and relatives, as well as for their own use. Popular “gift” items on sale in mainland China, for example, include Yunnan Baiyao, an all-purpose powder medicine said to be good for most diseases, and Paochiwan, pills that treat bowel complaints, seasickness, and a miscellany of other ailments. The latest fad is melatonin, a kind of hormone said to help people readjust their biological clocks, improve the quality of sleep, prevent aging, and even inhibit cancer.
People believe in medicine as a kind of beneficial supplement, good for their general well-being, especially when the effects are fast and visible. Doctors are well aware of this, and they frequently prescribe more medication than is needed to cure the ailments they have just diagnosed. The Department of Health (DOH) has no hard-and-fast data on physicians’ prescribing patterns and profiles, although one survey it conducted did show a tendency to overprescribe.
“We did a survey on patterns of prescribing some years prior to the introduction of the national health insurance (NHI) program in 1995,” says Hsiao Mei-ling (蕭美玲), director of the DOH’s Bureau of Pharmaceutical Affairs. “We found that it was not uncommon for a physician to combine four or five kinds of drugs in one prescription, whereas doctors in other countries usually prescribe only one or two at a time.” It is necessary to treat this survey with caution, however, because as Hsiao points out: “It was conducted on a limited scale. Besides, doctors here could well argue that their prescriptions often cover over-the-counter as well as prescription drugs in the strict sense, which naturally boosts the total number of drugs prescribed.”
Wu Kun-kuang (吳坤光), president of the China Medical Association and owner of a private gynecology and obstetrics clinic, thinks that unscrupulous pharmacists, rather than doctors, are to blame for medicine overuse. When doctors do prescribe more than necessary, perhaps throwing in a few stomach pills and vitamins, they do it out of concern for the patient’s psychological welfare. “Some patients just don’t feel it right if you give them only one drug for a sore throat,” he maintains. “So you add some painkillers, some pills for clearing the phlegm, and so forth. Can you call that overprescription?”
Whatever the motive, there is no denying that Taiwan people do spend a considerable amount of money on medicine. According to figures compiled by the Bureau of National Health Insurance (BNHI), the bureau is paying out slightly more than NT$50 billion [US$1.8 billion] a year to reimburse the cost of the drugs dispensed at the island’s approximately 14,000 NHI-contracted clinics and hospitals. The figure includes both Chinese and Western medical care. This means that each person spends around US$90 a year on medicine, and the figure goes up if the cost of drugs sold over the counter is included.
A particularly worrying aspect of this surging market is the use of antibiotics. Despite being classified as prescription drugs, antibiotics are often sold at pharmacies without prescription, which is illegal. In any case, local doctors tend to prescribe antibiotics for just about everything. A survey by Mackay Memorial Hospital vice president Huang Fu-yuan (黃富源) and Lai Mei-shu (賴美淑), director of the DOH’s Bureau of Health Promotion and Protection, showed that 90 percent of the prescriptions for newborn babies and children aged under six contained antibiotics. This astonishing figure emerged from a 1995 study of nearly 3,500 prescriptions taken from group medical centers and the DOH’s own public health clinics in Taipei and Kaohsiung. A National Taiwan University Hospital (NTUH) survey found that the situation was not much different in the case of adults.
Indiscriminate use of antibiotics can give rise to grim consequences. Hsiao Mei-ling refers to a research paper published last year by Chang Shang-chuen(張上淳), an NTUH physician. “According to Chang, some of Taiwan’s bacteria have made it to the top of the scale in terms of ability to develop resistance against antibiotics,” she says. “This means that our doctors may soon be running out of weapons in the fight against bacterial infections.”
What is behind the improper use of medicines? “Irrational drug therapy is a problem that exists all over the world,” says Hsieh Yen-yao (謝炎堯), an internist in cardiology at Sun Yat-sen Hospital. “It’s because new drugs are being developed by leaps and bounds, and doctors’ continuing education programs can’t catch up with pharmaceutical development.”
Hsieh gained considerable experience in this field while he was doing research work at NTUH, but even he has to acknowledge the existence of gray areas. “Sometimes it’s hard to define what is irrational drug therapy and what isn’t,” he admits. “Some antibiotics are actually quite toxic: they affect your kidneys, they damage your hearing. So what happens when a doctor knows that if he uses a given antibiotic, the patient’s kidneys may be damaged and he could end up needing dialysis, or might go deaf? Is the doctor still going to use that drug? With each prescription, the doctor has to weigh a number of factors--acceptable margins of safety, effectiveness, rationality, and cost.”
Hsieh identifies another contributory factor: in a society where doctors are expected to come up with perfect cures, the temptation to practice defensive medicine can be overwhelming. For example, colds and flu are caused by viruses, not bacteria, and will eventually just go away; antibiotics are no use against them. But a doctor frequently cannot determine without further examination whether a fever or sore throat is viral or bacterial in source. “The doctor usually prefers to treat for bacteria, so as not to lose valuable time,” Hsieh says. “And besides, even if the doctor can tell what’s causing the cold or flu, there’s no guarantee that the symptoms won’t develop into a bacterial infection. When you’re treating children or the elderly, who have weak resistance, it may be too late for treatment once the infection has gotten a hold. So antibiotics are used as a preventive measure to ward off infection.” According to Hsieh, doctors are increasingly worried by the possibility of crippling damage suits, or even criminal charges, when therapy goes wrong.
There is another reason why doctors sometimes overprescribe, and it does the profession no credit. Dispensing medicines is a profitable enterprise. In almost all of Taiwan’s private clinics, medicines are dispensed by the doctor or an employee of the doctor, rather than by professional pharmacists. Some physicians view the profits this activity generates as compensation for the unreasonably low professional fees they are allowed by BNHI. Hsieh does not deny the phenomenon, but he is disinclined to blame the medical establishment. “In the past,” he says, “when health care was covered by labor or farmer insurance programs, a doctor got NT$120 [US$4.37] for treating a patient; now he gets NT$220 [US$8], which seems high when compared with the old system, but the thing is, it costs more than that to have your hair done at a beauty salon. It’s the unreasonableness of the system that leads some doctors to practice irrational drug therapy.” And although Hsieh does not mention it, inflation also has to be factor ed into the equation.
Giving physicians the right to dispense has another drawback: it makes it difficult for responsible government agencies or research institutes to obtain comprehensive information about patterns of prescribing. This in turn leads to problems in detecting irregularities on the part of both doctors and pharmacists. Hsiao Mei-ling of the DOH is well aware of the difficulties she faces. “My first priority as director of the Bureau of Pharmaceutical Affairs is to supervise the use of prescription drugs,” she says. “But today, there is simply no effective control mechanism in place. What we need to do is separate dispensing from medical practice.”
Such a system is in fact supposed to come into force on March 1 this year, when an amendment to the existing law makes separation of dispensing from medical practice compulsory. Under the new law, doctors’ prescriptions will be dispensed at an NHI-contracted pharmacy of the patient’s choice, at no extra cost.
When doctors first got wind of this proposal, they were not amused. Pharmacists were also concerned, but for the opposite reason--they feared last-minute changes or compromises might sabotage their decades-long campaign for the exclusive right to dispense. In the run-up to March 1, petitions, demonstrations, lobbying, and even the trading of verbal insults by both interested professions became a lively feature of the Taiwan scene. As the two groups noisily competed for the public’s attention and sympathy, relations between them worsened. At stake was a market worth NT$40 billion [US$1.45 billion] a year. That is a conservative estimate; the figure goes much higher if sales of over-the-counter drugs are included.
Wu Kun-kuang of the China Medical Association argues that the new policy is seriously flawed. According to him, Taiwan’s pharmacists receive inadequate training, especially when it comes to their clinical internship (a bare two months, compared to the 1,500 hours required in the United States). Taiwan also recognizes certified assistant pharmacists, who can dispense non-narcotic medicines, but who are graduates of designated medical vocational high schools, not colleges. As a result, many doctors are concerned about the quality of dispensing and fear a possible increase in the number of medical disputes.
Wu stresses that doctors are not opposing the policy for the sake of it, but are protesting out of concern for public safety. He also points to the fact that “For the past 100 years or so, patients have been getting their prescriptions dispensed at the clinic where they’re treated. It’s safe, because doctors have their reputations to think about, and it’s convenient, because patients don’t need to travel between the clinic and the dispensary.”
Convenience is an important consideration for many patients, and doctors practicing in private clinics fear that it may influence them to make even greater use of large hospitals than they do at present. This is because such institutions dispense their medicines in-house. “According to a BNHI survey conducted toward the end of 1996, one-fifth of the patients who used to visit private gynecology and obstetrics clinics have already been swallowed up by the larger hospitals,” Wu says. “Once the policy of separation is fully implemented, patients are even more likely to prefer hospitals that function like one-stop hypermarkets--everything you need in one visit--to private clinics. It’s even going to make a dent in outside BNHI-contracted pharmacies, because the larger hospitals are going to eat into their share of the market, especially when you bear in mind that the referral system is virtually non-existent here.”
Wu and his association are afraid that private clinics could lose more than half their existing business. So worried are they that the association is even considering boycotting the NHI program in protest. “We have only one request,” Wu says. “Respect people’s right to choose where to have their prescriptions filled.”
For Chen Wei-tah (陳威達), chairman of the National Union of Pharmacist Associations, whether doctors make more or less money under the NHI program is beside the point. “That’s not my problem,” he says. “A doctor can choose to withdraw from the NHI if he wants. BNHI gives us just NT$30 [US$1.10] for each prescription dispensed. It’s nothing. I might as well open a roadside food stand--I’d make the same amount of money and I wouldn’t need to pay taxes. What doctors should do is negotiate an increase in their fees, rather than fight with pharmacists over who should have the right to dispense medicines.”
Chen believes that patients have a right to know what kind of drugs they are taking and how to take them. It is a striking feature of dispensing in Taiwan that the patient hardly ever receives medicine in packaging that describes the contents. Someone who is allergic to antihistamine, for example, has no means of discovering from the outside of the bottle or box whether the contents are likely to heal or harm him. For such patients the services of a pharmacist are highly desirable, because most doctors are too busy to give them the necessary information.
There is also one important respect in which a pharmacist can actually stand as a necessary intermediary between patient and physician. “A prescription can function as a patient’s protective charm, especially when a medical dispute arises,” Chen says. “But if the prescription is kept at the clinic or hospital, it can easily be ‘doctored’ [by the staff there], leaving the patient with no protection.”
Chen also disagrees with Wu and his association when they castigate pharmacists as not up to their job. “About 2,500 out of a total of 30,000-plus existing pharmacies are designated NHI-contracted dispensaries,” he says, “so those 2,500 at least must meet all the DOH’s requirements. If they’re not qualified and up to the job, who is?”
Private clinics may have experienced a drop in business since the inception of the NHI program, but many pharmacies, especially older mom-and-pop operations, have suffered as well. “Before the NHI was introduced in 1995, the number of outpatient visits to clinics and hospitals was 15 million a year,” Chen says. “Now that’s increased to 24 million, and each additional visit takes business away from pharmacies.” He adds that some pharmacists have even resorted to breaking the law, selling prescription drugs and narcotics and even giving medical treatment, simply in order to survive.
“Clinics have monopolized dispensing for a long time,” Hsiao Mei-ling of the DOH points out. “But what happens there is that physicians are delegating dispensing to non-professionals, maybe their family members, which is illegal, while certified pharmacists can’t make a reasonable living. So you find some pharmacists leasing their licenses to ‘ghost’ pharmacies [where the pharmacist is nominally in charge, but the real owner is a layman].” In a comment reminiscent of Chen Wei-tah’s, she also expresses the view that pharmacists have an important educational role to play: “People feel too intimidated to ask physicians questions. Doctors often tell them, ‘You won’t understand, even if I tell you.’ The separation policy makes it possible for people to get advice from pharmacists about how to take their medicines properly.”
But Hsiao knows all too well that the public is aware of the existence of ghost pharmacies and in consequence has little faith in pharmacists. One of the DOH’s goals is to reverse that perception. To that end, it has come up with a new category known as NHI-contracted pharmacies. In order to qualify as such, a pharmacy must have an operating license. It must also be administered by a certified pharmacist or assistant pharmacist who can show that during the previous five years either he has had two years’ teaching experience in a teaching hospital, or he has practiced in a private dispensary for two years and taken forty hours of continuing education in pharmacology. Only NHI-contracted pharmacies are eligible to dispense and be reimbursed for prescriptions written by NHI-contracted clinics and hospitals.
Hsiao is also conscious of the problems physicians are facing, and would like to see the BNHI grant more incentives to doctors who show themselves willing to implement the separation policy. “In the United States, a physician charges US$50 per visit,” she notes. “But here a doctor gets only NT$220 [US$8] per visit under the NHI program and an extra NT$10 [35 cents] for each prescription written. It’s too little.” On the other hand, she emphatically disagrees with those critics who invoke inconvenience as an objection to the new policy. “Whatever brings safety brings inconvenience,” she says. “Take crossing the road, for example. The easiest way is to just go ahead and cross--why bother using the crosswalk? But that’s not the safe way, and it’s the same with the separation policy.”
Certain special-interest groups also stand to benefit from the separation of dispensing from medical practice, including various business conglomerates. Several drugstore chains already sell a wide range of over-the-counter drugs, cosmetics, and gift items, and such stores can easily be upgraded to full dispensaries when their owners judge the market ripe. So far, the major drugs wholesalers have kept a low profile in the dispute, watching developments closely while they decide whether to side with doctors or pharmacists.
Can individual pharmacies hope to compete with conglomerates that have large capital resources and long experience of retailing? Chen Wei-tah acknowledges the difficulties. “That’s why I say there’s no point in doctors complaining about pharmacists having the right to dispense medicines,” he says. “The two sides need to find some way of cooperating.”
January 15 is observed as Pharmacists Day, and this year the occasion was marked by two significant events. Chen Wei-tah’s National Union of Pharmacist Associations invited a number of pharmacists to talk about various aspects of the separation policy, to help prepare its members for the new order. And President Lee Teng-hui made a speech giving the separation policy his blessing. It therefore seems certain that the policy will be implemented, although DOH chief Chang Po-ya (張博雅) has indicated that before it is put into effect islandwide there will be trials restricted to Taipei and Kaohsiung. Hsiao Mei-ling, director of the Bureau of Pharmaceutical Affairs, is certainly optimistic. “Because it’s such a difficult task, even the slightest progress makes you feel you’ve achieved a lot,” she says. “The situation can’t be worse than it was before. You have to be optimistic, if you’re a government official.”
Once implementation gets under way, even on a limited basis, the separation policy may well turn out to be irreversible, as Chen Wei-tah predicts. Beneath the public expressions of confidence, however, undercurrents of hostile opinion continue to swirl. The pending shakeup of Taiwan’s medicine market looks bound to produce both big winners and heavy losers, but nobody can yet be sure who they will be.