Curb script costs? How on earth?
Dr Laurie Davis says irrational and constantly changing prices for generic drugs make it impossible for GPs to contain prescribing costs
As GPs, we are under ever-growing pressure to take price into account when we decide which drugs to prescribe. That task is made much harder by the illogical category M pricing structure, under which the Government agrees fixed reimbursement for retail pharmacists for off-patent drugs.
The category M prices are changed every three months and most of the changes are rises – an average of about 15 per cent this quarter. There are several major areas of illogicality:
1 Massive price rises for some widely used drugs. For example, the 600 per cent rise for hydrocortisone over the last six months has probably gone unnoticed by many GPs and dermatologists; 50g of hydrocortisone cream costs £17.50 and the ointment is £22.11. This is not an obscure drug and I don't understand why I can still buy 60g OTC at my pharmacist for £4. The NHS is being ripped off.
A further example is the doubling in cost of penicillin V 250mg over the past six months, with erythromycin up by 60 per cent too. In contrast, the price of ciprofloxacin 250mg has come down and is now cheaper than penicillin V. Price has been part of the basis of guidelines yet my straw poll of microbiologists revealed they had no idea of the price changes.
2 The unfathomable dose/price differential. Most drugs get more expensive as the dose rises, but some drugs now are cheaper as the dose goes up; for example verapamil 160mg tablets are cheaper than 80mg, levothyroxine 100µg are cheaper than 25µg among others.
3 Some drugs seem idiosyncratically expensive. Phenytoin sodium 100mg tablets are £48 for 28 whereas 28 capsules cost £2.83. I doubt many prescribers appreciate the cost of the distinction.
4 The most dramatic illogicality is the pack size variation. Logic suggests bigger packs ought to be more expensive yet a pack of
84 betahistine 8mg costs £5.25 whereas a pack of 120 cost £3.01; sulfasalazine gastroresistant tablets 500mg cost £50 for 100 – but buy 112 and it drops to £18.70. There are many other examples. Even worse, pharmacists can substitute the smaller pack sizes if they wish, and get reimbursed for them, negating the cost-saving efforts of a well-meaning prescriber.
5 Some of the generic substitutes are now substantially more expensive than the branded equivalents. Septrin 480 cost 15.5p each, while the generic equivalent is 37p. Perhaps more importantly, branded Ventolin, Beconase and Becotide inhalers are now half the price of the generic substitutes. Generic prescribing, traditionally viewed as good practice for most drugs, is worse than pointless in these situations.
Prescribing policies are too slow and clumsy to respond to these changes – they cannot be revised with every quarterly change to prices.
How on earth can we hope to contain our prescribing costs in the face of so many inconsistencies? Carefully created prescribing policies are turned upside-down.
I am keen to contain prescribing costs but I cannot keep up with the constant changes and nobody is making me, as a prescriber, aware of them.
Anyway, there seems little point in creating prescribing upheaval for our patients if the policy needs to be changed three months later, when the new prices are announced.
There is a danger that GPs, faced with such illogical and inconsistent pricing structures, will give up attempting to contain costs and 'just write prescriptions'.
Laurie Davis is a GP partner in Shrewsbury